The American journal of emergency medicine
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Case Reports
Aortic intramural hematoma and hepatic artery pseudoaneurysm: unusual complication following resuscitation.
We present a case of a 71-year-old woman with an unusual complication of aortic intramural hematoma and hepatic artery pseudoaneurysm following cardiopulmonary resuscitation and thrombolysis done for sudden cardiopulmonary arrest and pulmonary embolism. Patient was on Warfarin treatment for a prior history of pulmonary embolism and experienced recurrent cardiac arrests, which finally resolved after intravenous administration of thrombolytic agents. However, follow-up computed tomographic angiography revealed descending aortic intramural hematoma with intramural blood pool and concomitant liver laceration with hepatic artery pseudoaneurysm. ⋯ Although the use of thrombolytic agents in patients with pulmonary embolism and cardiac arrest is still a matter of debate, this case report supports the concept that thrombolysis has a role in restoring cardiopulmonary circulation, especially in recurrent cardiac arrests resulting from pulmonary embolism. On the other hand, this case also highlights the increased association of the bleeding-related complication as a result of vigorous efforts of cardiopulmonary resuscitation. Aggressive management with interventional radiology for hepatic pseudoaneurysm and conservative management of the aortic intramural hematoma resulted in favorable outcome for our patient.
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Interest in the use of dynamic ultrasound (US) for cricothyrotomy has sparked a debate regarding its applicability in a crash airway situation. Ultrasound-guided marking of the cricothyroid membrane (CTM) as a preintubation procedure may be better than the dynamic method. No prior study has evaluated the accuracy of using US to premark the CTM before attempted intubation. ⋯ Ultrasound marking of the CTM of healthy volunteers before simulated intubation accurately identifies the CTM after neck manipulation expected during a failed intubation. Further research is indicated to determine the clinical applicability of this model.
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In spite of general acceptance and validation of NEXUS (National Emergency X-Radiography Utilization Study) in the clearance of cervical spine (C-spine) immobilized patients, clinicians often elect to image NEXUS-negative patients in clinical practice. ⋯ Regardless of level of training, providers in our ED often imaged patients who met NEXUS low-risk criteria. This was mot common in geriatric patients who presented after falls. This digression from NEXUS led to the diagnosis of significant injuries in 2 patients which would otherwise have been missed.
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Case Reports
Transient left ventricular and stomach apical ballooning syndromes: when the trigger is also a clinical emergency.
A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with preserved basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. ⋯ In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment.
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A pelvic x-ray (PXR) can be used as an effective screening tool to evaluate pelvic fractures and stability. However, associated intra-abdominal/retroperitoneal organ injuries and hemorrhage should also be considered and evaluated in patients with major torso injuries. An abdominal/pelvic computed tomographic (CT) scan may provide higher resolution and more information than a PXR. The role of conventional PXRs was delineated in the current study in the context of the development of the CT scan. ⋯ For the management of patients with major torso injuries, the role of PXR is diminishing due to the development of the CT scan. However, the PXR is still valuable for patients who are in critical condition and have an obviously high probability of retroperitoneal hemorrhaging.