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Critical Care Neurocardiology

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Critical Care Neurocardiology Journal of Internal Medicine and Emergency Research ISSN: 2582-7367 Rao M S, et al, 2021- Intern Med Emerg Res Research Article Critical Care Neurocardiology 1KIMS Hospitals, Hyderabad, Telangana, India 1* 2 S Manimala Rao , Vivek Balijepalli 2AIG Hospital Gachibowli, Hyderabad, Telangana, India *Corresponding Author: Prof S Abstract Manimala Rao M.D,D.A Anesthesiologist And Critical Care Physician, Director Neurocardiology is a term which was coined in the early 80s. It is very Medical Education And Academics, Kims apt to use this word in critical care when one manages patients who Hospitals ,Hyderabad, Telangana, India. are admitted to critical care and develop both cardiac and Accepted Date: 05-11-2021 neurological problems simultaneously, one leading to the other. Published Date: 06-11-2021 Though they are viewed separately by the concerned specialists they Copyright© 2021 by Rao M S, et al. All are managed simultaneously in the ICU by the critical care physician. rights reserved. This is an open access We present two cases in this area The pathophysiology management article distributed under the terms of the is discussed. Creative Commons Attribution License, which permits unrestricted use, Keywords: Neurocardiology; Critical care; Diabetes. distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Cardiac disturbances are quite frequent in a importance of brain–heart interactions from stroke patient be it arrhythmia or LV the 80s onwards. However, many do not view dysfunction. It is becoming quite common to them together for management. These observe the heart and brain interaction in the relationships in terms of physiological, ICU. Critical care at its core takes into clinical and management issues daily are of consideration the human body in its entirety. utmost importance in critical care. So, the Hence the clinical management of the brain questions are, can we consider the term and heart disorders cannot be isolated. The Neurocardiology in critical care on a daily care of neurologic patient is influenced by basis? What are the interactions between the cardiac diseases, and likewise neurological brain and the heart and what is the concerned consideration is essential in many types of pathophysiology? How does it influence in heart diseases. Cardiologists and Neurologists the management and outcomes of patients? view heart and brain alone respectively and In the setting of Critical care, time and proper ignore the other. There is a lot of literature decision making is a crucial factor. How with evidence regarding the hemodynamic & intracranial dynamic Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 monitoring helps to determine the immediate Patient had sudden onset, left upper limb & and long-term management of the patient lower limb weakness associated with slurring and how it influences the outcome will be of speech & deviation of angle of mouth to the discussed. We present here a series of two right side since 1 day. Known alcoholic. cases which clearly depicted the alterations in Patient took treatment at a local hospital for the neuro-cardiac axis to reiterate the the above complaints. During his evaluation, importance of neurocardiology once again in he was found to have Antero septal MI, for the critical care setting. which he was started on antiplatelets and betablockers and referred to tertiary center Case 1 for further evaluation and management. 47-year-old male presented with h/o dry Patient vitals are given in Table 1. cough since 10 days. Clinical Examination Vitals 1. Conscious, oriented 2. HR – 120/min 3. BP – 100/60 mmHg 4. RR- 24/min 5. SPO2 – 88 % on room air 6. CVS – S1,S2 + 7. RS - BAE +, Crepts + 8. P/A – Soft 9. CNS • GCS – 15/15 • Pupils – B/L reacting to light • Power - Left UL 0/5 & Left LL 0/5 and Right UL and LL 5/5 respectively Table 1: Case 1 Clinical Examination. Necessary investigations were done for the above patient. Investigations given in Table 2. Investigations 1. CBP 10. Cl- - 98.2 2. Hb – 13.9 11. GRBS– 247 mg/dL 3. TLC – 11,400 12. HbA1c – 12.9 4. Platelets – 2 lakhs 13. Coagulation profile 5. Blood urea – 39 14. PT – 15.8/12.9 6. S. creatinine – 0.8 15. INR – 1.2 7. Electrolytes 16. APTT – 26/30 8. Na+ - 137 17. TSH – WNL 9. K+ - 4.2 18. Lipid Profile- WNL Table 2: Case 1 Investigations Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 Figure 1: ECG shows Antero-septal Wall MI. Figure 2: Right Lower zone consolidation & Pulmonary edema. Figure 3: 2D Echo - Large LV clot measuring 2.1 x 2.9cm RWMA involving the septum & Apex hypokinetic EF approx. 30%, Dilated LV Severe LV dysfunction. Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 Figure 4: Large Right MCA Infarct. Patient was found to have Antero septal MI. started but later changed to 3 percent NaCl. 2D Echo showed a large LV clot and RWMA Initially, patient developed worsening of with severe LV dysfunction. X-ray revealed symptoms and increase in hypotension & was pulmonary edema with right lower zone started on vasopressor support with pneumonia. MRI brain done revealed large noradrenaline and dobutamine. Later patient MCA territory infarction. condition showed improvement and was Treatment was initiated with empirical weaned off noradrenaline & dobutamine antibiotics for Right lower lobe pneumonia. infusion. For severe LV dysfunction, Inotropic support Repeat Echo–revealed mild improvement (Dobutamine), frusemide & Aldactone. with EF of 30 to 35%. Repeat CT brain showed Anticoagulation & antiplatelets. ACE- mild hemorrhagic transformation inside the Inhibitors and Statins. Mannitol was initially existing infarct. Figure 5: Mild hemorrhagic transformation inside the existing infarct. Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 During treatment, patient recovered from positive pressure ventilation) was instituted pulmonary edema and pneumonia. Patient in view of the florid pulmonary edema. showed improvement in motor power on left Patient had dyselectrolemia due to long term side with power of Left upper limb–2/5 and diuretic use. Patient had frequent ventricular left lower limb–3/5. Patient also had Recovery ectopics. CT angiogram revealed pulmonary of speech. Later patient shifted out of ICU and thrombo-embolism. There was severe PAH, subsequently discharged. In this difficult proBNP was 8749 and chest Xray showed clinical scenario coronary angiogram was not marked pulmonary oedema. Patient planned as the time delay was already existing developed mild weakness in the left upper and also patient had neurological problem. and lower limbs and the CT scan revealed very minimal hemorrhagic infarct. However, Case 2 aspirin and statins were continued, and cautious ant platelet medication usage A 52-year-old female, a known diabetic and a advocated. Slowly patient improved but case of dilated cardiomyopathy (DCMP) advised about her seriousness of her presented with acute heart failure. She was condition and to keep diabetes under good treated for heart failure with furosemide, control and to take medication regularly. dobutamine and BIPAP (non-invasive Clinical Examination Vitals Investigations 1. Patient conscious oriented CBP – WNL 2. PR – 108/min Na – 122.80 3. BP – 80/60 mmHg K – 3.59 4. SPO2 – 80 % on RA Cl – 84 5. Systemic Examination Pro BNP - 8749 6. RS – B/L AE + 7. CVS: S1 S2 + 8. P/A – Soft Table 3: Clinical Examination and Investigations. Figure 6: Marked Pulmonary Edema. Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 Figure 7: Decrease in Pleural Effusion & Cardiomegaly. Figure 8: Monomorphic VPC’s – Due to Dyselectrolytemia. Figure 9: CT pulmonary angiogram. PTE in the segmental branch of the right inferior lobar artery. Moderate Right Pleural effusion & mild left pleural effusion. Rao M S | Volume 2; Issue 1 (2021) | Mapsci-JIMER-2(1)-018 | Research Article Citation: Rao M S, Balijepalli V. Critical Care Neurocardiology. J Intern Med Emerg Res. 2021;2(1):1-9. DOI: https://doi.org/10.37191/Mapsci-2582-7367-2(1)-018 Figure 10: X ray after patient improvement. Patient’s condition improved with two organs has led to analyze the various conservative management. Pulmonary edema clinical dilemmas [4]. The neurocardiac axis cleared on X ray. Dyselectrolytemia was links the cardiovascular system to corrected. Patient discharged with stable physiological problems like arrhythmia, vitals with advice regarding her heart epilepsy and stoke. The brain controls the condition and need for heart transplant. heart rate through balance between the sympathetic and parasympathetic nervous Discussion system. A clear and distinct balance is required between these two systems for Neurocardiology is a term coined to study the pathophysiological aspects of cardiovascular neurophysiological and neuroanatomical system. An imbalance may happen due to aspects of cardiology specially including the hormones levels, stress, lifestyle and injury neurological origins of cardiac disease.
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