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P. Pascale

B. Quartenoud

“Thrombolysis”

by a neuromuscular blocking agent

Clin Res Cardiol 95:204–205 (2006)

DOI 10.1007/s00392-006-0357-z

CLINICAL PICTURES

Received: 16 November 2005 Accepted: 25 November 2005 Published online: 27 February 2006

Patrizio Pascale, MD · B. Quartenoud, MD Division of Cardiology

Department of Internal Medicine University Hospital Zurich 8091 Zurich, Switzerland Tel.: + 41-4 42 55 11 11 Fax: + 41-4 42 55 42 51

E-Mail: patrizio.pascale@usz.ch Authors’ institutions:

Intensive Care Unit Cantonal Hospital Fribourg, Switzerland

A 72-year-old man was brought to our intensive care unit for a community-acquired pneumonia compli-cated by septic shock with multiple organ failure. Mechanical ventilation was initiated upon admission. Three days later, the patient developed striking ST segment elevation on electrocardiogram raising con-cern of an ongoing cardiac event (Fig. 1). However, no hemodynamic repercussion was present. Serum electrolytes were normal.

A further electrocardiogram provided evidence of a noncardiac electrical activity with a baseline undu-lation of the electrocardiogram asynchronous with

the regular superimposed QRS complex (Fig. 2). The electrocardiogram normalized after administration of a neuromuscular blocking agent for the ventila-tory management of the acute respiraventila-tory distress syndrome (Fig. 3). The echocardiogram performed subsequently showed diaphragmatic myoclonus at a frequency similar to the heart rate [1–3]. On the first electrocardiogram performed, the superimposed electromyographic activity of the diaphragmatic flut-ter was incidentally in phase with the QRS complex and had therefore been misinterpreted as cardiac electrical activity.

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205 P. Pascale and B. Quartenoud

“Thrombolysis” by a neuromuscular blocking agent

Fig. 2

Fig. 3

References

1. Rigatto M, De Medeiros NP (1962) Diaphragmatic flutter: report of a case and review of the literature. Am J Med 32:103–109

2. Cvietusa PJ, Nimmagadda SR, Wood R, Liu AH (1995) Diaphragmatic flutter presenting as inspiratory stridor. Chest 107:872–875

3. Hoffman R, Yahr W, Krieger B (1990) Diaphragmatic flutter resulting on fail-ure to wean from mechanical ventilator support after coronary artery bypass surgery. Crit Care Med 18:499–501

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