Circulation 1961 HERSCH 853 60

7/25/2019 Circulation 1961 HERSCH 853 60

1/9

E l e c t r o c a r d i o g r a p h i c

C h a n g e s

i n

H e a d

I n j u r i e s

Bi

C O L I N

HERSCH,

M L B .

( R A N D ) ,

DI.

M E D .

( R A N D )

T

E

e l e c t r o c a r d i o g r a p h i c

p a t t e r n o f

1 6 4

p a t i e u t s w i t h h e a d

i n j u r y w a s s t u d i e d

a n d c o m p a r e d

w i t h t w o c o n t r o l g r o u p s : 1 0 0

p a t i e n t s w i t h

l i m b

t r a u m a

a u d

1 6 4

h e a l t h y

s u b j e c t s .

I n

t h e

g r o u p

w i t h

t h e h e a d

i n j u r y

t h e

e l e c t r o c a r d i o g r a p h i e

f i n d i n g s w e r e

c o r r e -

l a t e d w i t h t h e l e v e l o f

c o n s c i o u s n e s s .

T h e p o s s i b l e

r e l a t i o n s h i p b e t w e e n h e a d

t r a u m a

a n d

e l e e t r o c a r d i o g r a p h i c c h a n g e s

w a s

f i r s t

s u g g e s t e d

b y

B r a m w e l l . 1

l i e

d e s c r i b e d

a

m i n e r , a g e d 3 5

y e a r s , w h o ,

a f t e r

a b l o w o n i

t h e

h e a d

t h a t

d i d n o t c a u s e

h i m t o l o s e

c o l i -

s c i o u s n e s s , d e v e l o p e d a t r i a l f i b r i l l a t i o n

t h a t

l a s t e d

f o r 4 w e e k s . On

e x a m i n a t i o n o f

t h e

c a r d i o v a s c u l a r a n d c e n t r a l

n e r v o u s s y s t e m s ,

n o t h i u o g

a b n o r m a l

was

f o u n d .

L u c k e 2 d e s c r i b e d

a 5 4 - y e a r - o l d

man

who

f e l l

f r o m

a l a d d e r a n d w a s f o u n d t o

h a v e

b l o c k e d a t r i a l

e x t r a s y s t o l e s

a f t e r

a

l ) e r i o d

o f

c o n c u s s i o n .

I l i s

c a r d i o v a s c u l a r s y s t e m

was

c l i n i c a l l y

n o r n i a l .

D o r e t

a n d

F o r r e r o 3

s t u d i e d

3 2 c a s e s

o f

t r a u m a t i c

e n i e e p h a l o p a t h y

w i t h o u t c l i n i c a l

e v i d e n c e o f

c a r d i o v a s c u l a r

d i s e a s e . T h e y d e -

s c r i b e d v a r i o u s c h a n g e s b u t

d i d

n o t

f i n d a

c h a r a c t e r i s t i c

e l e e t r o c a r d i o g r a p h i c

t r a c i i l w t .

T h e y

d i v i d e d t h e i r c a s e s

i n t o

s i x

' s y m p a -

t h e t i c o t o n i e '

( t a c h y c a r d i a ,

r a i s e d

P

w a v e s

i n

l e a d s

I T

a n d

I I I ,

s h o r t

P-R

i n t e r v a l ,

i n -

c r e a s e d

Q - T

i n t e r v a l ,

a n d

s h a l l o w

T

w a v e s ) ,

f o u r

p a r a s y m ) a t h e t i c o t o n i c

( b r a d y e a r d i a ,

d e p r e s s e d

P

w a v e s , i n c r e a s e d P-R i n t e r v a l ,

s h o r t Q - T

i n t e r v a l ,

a n d t a l l

T w a v e s ) , a n d

2 2

i n t e r m e d i a t e t y p e s .

I n

a d d i t i o n ,

o n e c a s e

h a d v e n t r i c u l a r

e x t r a s v s t o l e s a n d o n e

c a s e

h a d

p a r o x y s m a l

s u p r a v e n t r i e u l a r

t a c h y c a r d i a .

S i n u s r h y t h m

w a s p r e s e n t i n 2 3 e a s e s

a n d

s i n u s

a r r h y t h m i a

i n

n i n e .

N a d a s e t

a l . 4 d e s c r i b e d a 5 - y e a r - o l d

g i r l

who

h a d

a n o r m a l

p u l s e

4

w e e k s

p r i o r

t o a

h e a d

i n j u r y .

S h e

was

u n c o n s c i o u s

f o r

5

m i n -

From

t h e

1 ) e p a r t m e n i t

o f

M e d i c i n e , B a r a g w a I I a t h

H o s p i t a l ,

J o h a n n e s b u r g ,

S o u t h

A f r i c a .

C i r c u l a t i o n ,

Volume

X X I I I ,

June

1 9 6 1

t i e s

a n d a f t e r

t h e i n j u r y d l e v e l o p e d

p a r o x -

s s m a l

v e n t r i c u l a r t a c l h y c a r d i a

c o n f i r m e d

b y

e l e c t r o c a r d i o g r a p h y .

Her

c e n t r a l n e r v o u s

s y s -

t e m a n d c a r d i o v a s c u l a r s y s t e m s

w e r e

e l i n i -

c a l l y i i o r m a l ,

a n d

x - r a y e x a m i n a t i o n

s h o w e d

a f r a c t u r e o f

t h e

b a s e

o f

t h e

s k u l l .

E l e e t r o e a r d i o g r a p h i c

c h a n g e s

h a v e

a l s o

b e e n

n o t e d d u r i n g b r a i n

o p e r a t i o n i s , 5

l u m b a r

p u n c t u r e 0

a n d

p n e u m o e n i e e p h a l o ( r r a p h y , 7

i l l

c e r e b r a l

t u m o r s , 8

p o l i o m n y e l i t i s , 9

a n d i l l

c e r e -

b r a l

h e m o r r h a g e . 1 0

A M u c h e x p e r i m e n t a l w o r k

h a s b e e n p e r -

f o r m e d t o

d e t e r m i n e

t h e r o l e p l a y e d

b y

t h e

c e n t r a l

n e r v o u s s y s t e m n

i l l t h e p r o d u c t i o n

o f

c a r d i a c

i r r e g u l a r i t i e s .

B e a t t i e , B r o w ,

a i i d

L o n ( g 1

p r o d u c e d e x t r a s y s t o l e s

b y s t i m u l a t i o i

o f

t h e

p o s t e r i o r

h y p o t h a l a m n u s

i l l

a i i e s t h e t i z e d

c a t s .

A

d e s t r u c t i v e

l e s i o n

o f t h e

p o s t e r i o r

h y p o t h a l a m u s

o r s e c t i o n

o f t h e

b r a i n b e h i n d

t h i s

l e v e l

c a u s e d t h e s e


t o d i s -

a p p e a r .

S t o r n i v a l l L e e u w e n 1 ' 2 o b s e r v e d

n o d a l a n d

v e n t r i c u l a r

r h y t h m i

s h i f t o f t h e s i n i o a t r i a l

l a c e m a k e r ,

a n d

m u l t i f o c a l


o n

s t i m u l a t i n g t h e

b r a i n l s

o f c a t s b e t w e e n t h e

l o s t e r i o r

c o r p o r a

q u a d r i g e m i n a

a n d t h e

p o s -

t e r i o r

p o r t i o n s o f t h e c e r e b e l l u m .

E x p e r i m e n t a l s t i m u l a t i o n o f

s u b e o r t i c a l

a r e a s i l l c a t s b y K o r t e w e g e t a l . ' : y i e l d e d t h e

f o l l o w i n i g

r e s u l t s :

S t i m u l a t i o n

o f

t h e

b a s a l

g a n i r l i a

r e s u l t e d

i m n u e d i a t e l y i n o c c a s i o n a l

e x t r a s y s t o l e s .

S t i m n u l a t i o n o f t h e

p o s t e r i o r

h y p o t h a l a m u s a n d t h e

q u a d r i g e m i n a l

b o d i e s

p r o d u c e d v e n t r i c u l a r

e x t r a s y s t o l e s ,

w a n d e r -

i n g

p a c e m a k e r ,

a n d T - w a v e c h a n g e s .

A f t e r

s t i m u l a t i o n h a d c e a s e d , v e n t r i c u l a r

e x t r a s y s -

t o l e s ,

a t r i o v e n t r i e u l a r d i s s o c i a t i o n , w a n d e r i n g

p a c e m a k e r , t a c h y c a r d i a ,

a n d T - w a v e c h a n g e s

w e r e

n o t e d ,

a l l

o f

w h i c h w e r e

a b o l i s h e d b y

v a g a l

s e c t i o n .

A

s t u d y

o f


c h a n g e s

i n

h e a d

trauma was

made b v J a c o b s o n a n d

D a n u f s k v 1 4

i n

1 5 A l b i n o

S w i s s

m i c e .

A l l

t h e

8 5 3

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2/9

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a u t h o r s

t h e r e f o r e

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3/9

E L E C T R O C A R D I O G R A M

IN

HEAD

I N JURI E S 8 5

F i g u r e

2

A

f i r s t

s h o w s

an

i n c r e a s e i n t h e

Q - T ,

i n t e r v a l .

L a t t e r t h e

Q - T

i n t e r v a l was n o r m a l .

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t r a c i n g s f r o m

t w o o t h e r

p a t i e n t s ( B

a n d

C ) l a r g e

U

waves a r e

p r e s e n t ,

b e s t s e e n

i n

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T a b l e 2

A r r h y t h m i a s

G r o u p

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G r o u p

B

G r o u p

C

S i n u s

A r r h y t h m i a

( a )

f i x e d

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3 % 0

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p a c e m a k e r

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Volume

X X I I I ,

June 1 9 6 1

S u b j e c t s

a n d M e t h o d s

T h r e e

g r o u p s

o f

p a t i e n t s

were

s t u d i e d .

G r o u p

A

c o n s i s t e d o f

1 6 4

B a n t u

p a t i e n t s ( 1 5 8

m a l e

a n d

6

f e m a l e )

w i t h

h e a d

i n j u r y ,

who

were

a d m i t t e d

t o

B a r a g w a n a t h H o s p i t a l

o v e r

t h e

p e r i o d

M a r c h

1 9 5 7

t o

M a r c h 1 9 5 8 .

T h e r e were

t w o

c o n t r o l

g r o u p s :

G r o u p

B c o n -

s i s t e d

o f 1 0 0 c o n s e c u t i v e B a n t u

p a t i e n t s

who

s u s t a i n e d t r a u m a

c o n f i n e d

t o

e i t h e r

t h e

u p p e r

o r

l o w e r l i m b s . T h e s e c a s e s

c o m p r i s e d f r a c t u r e s ,

d i s l o c a t i o n s ,

t r a u m a t i c

a m p u t a t i o n s ,

a n d

b u l l e t

w o u n d s . No

p a t i e n t s

were

u n c o n s c i o u s o r

r e q u i r e d

b l o o d t r a n s f u s i o n .

G r o u p

C

was m a d e

up

o f

1 6 4

h e a l t h y

B a n t u

s u b j e c t s

o f

a g e

a n d s e x

d i s t r i b u t i o n

s i m i l a r

t o

g r o u p

A .

A l l t h e

p a t i e n t s

i n

g r o u p

A were u n d e r 4 0

y e a r s

o f

a g e

a n d a l l h a d a

h i s t o r y

o f

i m p a i r e d

c o n s c i o u s n e s s .

I n

no

c a s e was

t h e r e c l i n i c a l

e v i -

d e n c e o f c a r d i o v a s c u l a r d i s e a s e . E l e c t r o c a r d i o -

g r a m s

were

p e r f o r m e d

w i t h i n 1 8

h o u r s

o f

a d m i s s i o n

t o

t h e

h o s p i t a l .

T h e

c a s e s

were

c l a s s i f i e d

i n t o

g r o u p s a c c o r d i n g

t o l e v e l o f c o ns c i o u s ne s s a t

t h e

t i m e

o f t h e

e l e c t r o c a r d i o g r a m s : g r o u p

1 was

m e n t a l l y

n o r m a l

( 1 0 3 c a s e s ) ,

g r o u p

2

was

d r o w s y

8 5 5



4/9

HERSCJI

F i g u r e

3

L e f t .

The

T

waves

were

i n v e r t e d

i n t h e

t h r e e

s t a n d a r d

l e a d s ,

a v e r

and

V 2

t o

V 6 .

F o ur

d a y s

l a t e r ,

r i g h t ,

T

waves b e c a m e

u p r i g h t

e x c e p t i n

l e a d

III.

The

S - T ' s

were e l e v a t e d

i n t h e s t a n d a r d an d

pre -

c o r d i a l

l e a d s ,

more

m a t r k e d

i n

t h e

l a t e r

t r a c i n g .

( 1 2

c a s e s ) , group

3

was s t u p o r o u s

( 2 9 c a s e s ) , and

g r o u p

4

was

comatose ( 2 0

c a s e s ) . Eleven

p a t i e n t s

d i e d ,

and

n e c r o p s i e s

were

performed

i n

a l l c a s e s .

R e s u l t s a n d

Comment

T h e

e l e c t r o c a r d i o g r a p h i c f i n d i n g s

were d i -

v i d e d

i n t o

t h e

two

c a t e g o r i e s o f

c h a n g e s

i n

c o m p l e x e s ( t a b l e

1 )

a n d c h a n g e s

i n

rhythm

( t a b l e 2 ) .

T h e

s i g n i f i c a n t

f i n d i n g s may

b e

c l a s s i f i e d

a s

f o l l o w s :

C h a n g e s O c c u r r i n g

More

Commonly

i n t h e

Head

I n j u r y

Group

Than

i n

t h e C o n t r o l

G r o u p s

P

w a v e s

o f i n c r e a s e d

a m p l i t u d e

( f i g .

1 )

w e r e f o u n d

much more c o m m o n l y i n

t h e

p a -

t i e n t s w i t h

h e a d

i n j u r y

t h a n

i n t h o s e

w i t h

l i m b

t r a u m a

( p

=

< 0 . 0 5 ) .

I n

t u r n ,

t h e

i m c i -

d e n c e

o f

t a l l

P w a v e s i n t h e

l a t t e r

g r o u p

w a s

much

h i g h e r

t h a n

t h a t

i n t h e

h e a l t h y

c o n t r o l s

( p

=

< 0 . 0 5 ) .

I n t h e

h e a d

i n j u r y g r o u p t h e t a l l P

w a v e s

w e r e a s s o c i a t e d w i t h

h e a r t

r a t e s a b o v e

9 0

p e r

m i n u t e i n 6 1

p e r c e n t

o f c a s e s

( t a b l e

3 ) .

I t

i s

p o s s i b l e

t h a t

t h e s e P

w a v e s w e r e

d u e t o

s y m p a t h e t i c

s t i m u l a t i o n ,

s i n c e s i m i l a r

P

w a v e s h a v e b e e n n o t e d

d u r i n g e x e r c i s e , 1 7 5

a n x i e t y , ' 6

h y p o x i a , 1 7 a n d

f o l l o w i n g

t h e

a d -

m i n i s t r a t i o n

o f

e p i n e p h r i n e . 5

I n

t h e

r e m a i n -

i n g

c a s e s

t a l l

P

w a v e s

w e r e

f o u n d w i t h

h e a r t

r a t e s

f r o m 5 5 t o 9 0 p e r

m i n u t e , w h i c h

s u g g e s t s

t h a t f a c t o r s o t h e r t h a n

s y m p a t h e t i c s t i m u l a -

t i o n w e r e

o p e r a t i v e .

A n

i n c r e a s e d

Q - T ,

i n t e r v a l w a s

v i r t u a l l y

c o n f i n e d

t o

t h e h e a d

i n j u r y

g r o u p ,

o c c u r r i n g

i n

1 5 p e r c e n t o f t h e c a s e s

( f i g . 2 A ) .

T h e

i n c r e a s e d

Q - T ,

i n t e r v a l ,

l i k e s o m e o f

t h e t a l l

P

w a v e s ,

may b e d u e t o

s y m p a t h e t i c

s t i m u l a t i o n .

I n

man t h e i n j e c t i o n

o f e p i n e p h -

r i n e r e s u l t s i n

a n

i n c r e a s e o f

t h e

Q - T ,

i n t e r v a l . ' 8

Of

t h e

p a t i e n t s w i t h

a n i n c r e a s e d

Q - T , .

i n t e r v a l ,

o n l y 3 6

p e r

c e n t

w e r e a c c o m p a n i e d

b y

h e a r t r a t e s

o f

o v e r 9 0 p e r m i n u t e

a n d

3 2

p e r c e n t a l s o

h a d t a l l P w a v e s .

C h a n g e s

That Appeared

t o

B e

a

N o n s p e c i f i c

R e a c -

t i o n

t o

Trauma

T h e s e

e h a n g e s

o c c u r r e d w i t h

s i m i l a r f r e -

q u e n c y

i n

b o t h

t h e

g r o u p s

w i t h

t r a u m a

( A

a n d

B ) .

At

t h e s a m e t i m e

t h e i n c i d e n c e

o f

t h e

c h a n g e s

i n

t h e s e g r o u p s was g r e a t e r

t h a n

i n

t h e

h e a l t h y c o n t r o l

g r o u p

C .

T h e p v a l u e s

g i v e n

b e l o w

d e s i g n a t e t h e

l e v e l

a t w h i c h t h e

d i f f e r e n c e b e t w e e n

t h e

t r a u m a t i c

g r o u p s

a n d

t h e

h e a l t h y

c o n t r o l s

was s i g n i f i c a n t .

1 .

I n c r e a s e d

QR S

v o l t a g e

i n

t h e

p r e c o r d i a l

l e a d s

( p

=

0 . 0 2 ) .

2 .

R a i s e d

S - T

s e g m e n t s

( f i g .

5 )

i n

p r e -


Volume

X X I I I ,

June

1 9 6 1

8 5 6



5/9

ELECTROCARDIOGRAM IN HEAD

I N JURI ES

F i g u r e

4

A .

V e n t r i c u l a r

e c t o p i c

b e a t s

were

p r e s e n t

( u p p e r )

and

l a t e r

( c e n t e r )

t h e


e c t o p i c

b e a t s

c o n s t i t u t e d

t r i g e m i n a l r h y t h m .

Note

a l s o

t h e

t a l l

P

waves.

B . Shows

s i n u s

a r r h y t h m i a

w i t h a

f i x e d

p a c e m a k e r

and an a t r i a l

e c t o p i c

b e a t .

c o r d i a l

l e a d s

( p

=

0 . 0 1 ) .

I t

i s o f

i n t e r e s t

t h a t

4 8

p e r c e n t o f

t h e

h e a l t h y Bantu

c o n t r o l s

h a d

i n c r e a s e d QR S

v o l t a g e

b y

s t a n d a r d s e s t a b -

l i s h e d f o r

w h i t e s u b j e c t s

( S o k o l o w

and

L y o n 1 9 ) .

A l s o ,

r a i s e d

S - T

s e g m e n t s

were

f o u n d i n

3

p e r

c e n t

o f

s u c h

c o n t r o l s .

B o t h

i n c r e a s e d QR S

v o l t a g e

a n d

r a i s e d S - T seg-

ments

h a v e

p r e v i o u s l y

b e e n

d e s c r i b e d

b y

G r u s i n

i n

n o r m a l

B a n t u . 2 0

3 .

I n v e r t e d

T

waves

i n

p r e c o r d i a l

l e a d s

V ,

T a b l e

4

C h a n g e s

i n I n d i v i d u a l

E l e c t r o c a r d i o g r a p h i c

C o m p o n e n t s

Group

1

Group

2

Group

3

Group

4

1 0 3 C a s e s

1 2

C a s e s 2 9

C a s e s

2 0 C a s e s

Type o f c h a n g e

P

w a v e s 2 . 5 mm.

2 3

( 2 2 . 3 )

3

( 2 5 6 X , )

9

( 3 1 / o )

5

( 2 5 )

o r

more

I n c o m p l e t e

r i g h t

5

(

4 . 8 % T )

0

1

( 3 % S )

1 (

5 % 0 )


b l o c k

P r o l o n g e d

Q - T ,

1 6

( 1 5 . 5 )

0

6

( 2 1 )

4

( 2 0 )

S - T

s e g m e n t r a i s e d

more

t h a n

2 . 5 mm.

1 1

( 1 0 . 7 )

3

(25 )

4

( 1 4 % c , )

4

( 2 5 o )

i n V

l e a d s

I n v e r t e d

T

w a v e s

V 4 - 0

7

( 6 . 8 )

2

( 1 7 )

3

( 1

0 r )

4

( 2 0 o )

U

waves t a l l e r t h a n 1 1

( 1 0 . 7 )

1

( 1 7 )

1 0

( 3 4 % / )

1 3

( 6 5 )

mm.

Type

o f

a r r h y t h m i a

S i n u s

A r r h y t h m i a

( a )

f i x e d

p a c e m a k e r

7

(

6 . 8 % c )

3

( 2 5 )

5

( 2 1 )

2

( 1 0 )

( b ) p a c e m a k e r

w a n d e r i n g

3

(

2 . 9 % , )

2

( 1 7 )

3

( 1 0 % l )

4

( 2 0 )

i n

s i n o a t r i a l n o d e

( c ) p a c e m a k e r

w a n d e r i n g

t o


1

(

. 9 ' A )

1

(

8 C / . )

1

(

3 % / )

2

( 1 0 C / )

n o d e

2

( 1 7 / 7 )

1 (

3 % o )

4

(20 )

E x t r a s y s t o l e s

2

(

1 . 9 )

Nodal

r h y t h m

1

(

. 9 % , ) 1 (

8 )

0

4 ( 2

0 r )

A t r i o v e n t r i c u l a r

b l o c k

0

0 0

1

(5)

T o t a l

number o f

c h a n g e s

8 7

1 8

4 4

4 8

T o t a l

a v e r a g e number

. 8 4 1 . 5 0

1 . 5 2

2 . 4 0

o f

c h a n g e s p e r

case


Volume

X X I I I ,

June

1 9 6 1 i

8 5 7



6/9

H E R S C H

1

A

a 3

B

752

t

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - ' ' ' - -

- -- - - - - -

52

F ~~~~~~G

1 . ,6MAY58

MA Y

1NOV58

Figure

5

A

shows

u w a d e r i n g

of

the

Pacemaker

in

the

sinoatrial

node. In

B

the

pacemtaker

wanders

to

the

atrioventricular

node.

A

V a l s a l v a

maneuver

(x)

results

in

sinus

r - h y t h m n

( C ) .

After

the

Valsalva

m a n e u v e r . ,

D

shows

wandering

o

f

t h ~ e

pacemaker

to the

atrioventricular

node and

E

shows

nodal

rhythm.

Four

days

later,

F

and G show

wandering

o f

the

pacemaker

in

the

atrio:entricular

node. Sinus

rhythm

i s restored

3

days

later

(H

and

i).

5;Bz

t +w

^-- +

+ *

t

:

...

. ft t

j ~ t .

.;

t^

.,i

Y:ws

:

_ ~ . o ,

< : t

m

: e > e s e < < e

: . . s : . .

> - F F :

Documents

Circulation 1961 HERSCH 853 60