Arterial embolization of an extrapleural hematoma from a dislocated fracture of the lumbar spine: a case report

<p>Abstract</p> <p>Background</p> <p>We present a report of a blunt-trauma patient who developed an atypical extrapleural hematoma with hemodynamic instability following a dislocation fracture of the first lumbar vertebra. We successfully treated her with arterial embolization (AE) of the lumbar and intercostal arteries.</p> <p>Case report</p> <p>The patient, a 74-year-old woman, was injured in a traffic accident. At the scene of the accident, she was found to be alert, and her hemodynamic condition was stable. She arrived at our hospital complaining of lumbago. A thoracoabdominal computed tomography (CT) scan with contrast enhancement showed a dislocation fracture of the first lumbar vertebra along with paravertebral and retroperitoneal hematomas. Therefore, we managed the patient conservatively with bed rest. However, 3 h after admission, her blood pressure suddenly decreased. A repeated thoracoabdominal CT scan showed enlargement of the right retroperitoneal hematoma with extravasation of the contrast medium into the right extrapleural space. Angiography was immediately performed, showing extravasation of the contrast media from the right intercostal (Th12) and lumbar arteries (L1). After arterial embolization (AE) with gelatin-sponge particles, extravasation of the contrast medium ceased, and the patient's hemodynamic condition stabilized without massive fluid resuscitation.</p> <p>Conclusion</p> <p>The extrapleural hematoma reduced in size after AE, and almost disappeared on the 14^thday of hospitalization. The lumbar spinal fracture was successfully repaired on day 16, and the patient was kept in the hospital to recuperate. We believe that AE is effective for the management of intractable bleeding following fractures of the spine.</p

A 92-year-old man with retropharyngeal hematoma caused by an injury of the anterior longitudinal ligament

AbstractTraumatic retropharyngeal hematoma is a rare condition and may be lethal in some cases. In patients with this condition, the absence of a vertebral fracture or a major vascular injury is extremely rare. We present the case of a 92-year-old man who hit his forehead by slipping on the floor in his house. He had no symptoms at the time; however, he experienced throat pain and dyspnea at 6 hours after the injury. On arrival, he complained of severe dyspnea; therefore, an emergency endotracheal intubation was performed. A lateral neck roentgenogram after intubation showed dilatation of the retropharyngeal and retrotracheal space and no evidence of a cervical vertebral fracture. Cervical computed tomography (CT) with contrast medium revealed a massive hematoma extending from the retropharyngeal to the superior mediastinal space but no evidence of contrast medium extravasation or a vertebral fracture. However, sagittal magnetic resonance imaging (MRI) revealed an anterior longitudinal ligament (C4-5 levels) injury. We determined that the cause of the hematoma was an anterior longitudinal ligament injury and a minor vascular injury around the injured ligament. Therefore, we recommend that patients with retropharyngeal hematoma undergo sagittal cervical MRI when roentgenography and CT reveal no evidence of injury

Arterial embolization in patients with grade-4 blunt renal trauma: evaluation of the glomerular filtration rates by dynamic scintigraphy with 99mTechnetium-diethylene triamine pentacetic acid

<p>Abstract</p> <p>Background</p> <p>High-grade blunt renal trauma has been treated by arterial embolization (AE). However, it is unknown whether AE preserves renal function, because conventional renal function tests reflect total renal function and not the function of the injured kidney alone. Dynamic scintigraphy can assess differential renal function.</p> <p>Methods</p> <p>We performed AE in 17 patients with grade-4 blunt renal trauma and determined their serum creatinine (sCr) level and glomerular filtration rate (GFR; estimated by dynamic scintigraphy) after 3 months. In 4 patients with low GFR of the injured kidney (<20 ml·min^-1·1.73 m^-2), the GFR and sCr were measured again at 6 months. Data are presented as median and interquartile range (25th, 75th percentile).</p> <p>Results</p> <p>The median GFR of the injured kidney, total GFR, and median sCr at 3 months were 29.3 (23.7, 35.3) and 96.8 (79.1, 102.6) ml·min^-1·1.73 m^-2and 0.6 (0.5, 0.7) mg/dl, respectively. In the patients with low GFR (ml·min^-1·1.73 m^-2), the median GFR of the injured kidney, total GFR, and median sCr (mg/dl) were 16.2 (15.7, 16.3), 68.7 (61.1, 71.6), and 0.7 (0.7, 0.9), respectively, at 3 months and 34.5 (29.2, 37.0), 90.9 (79.1, 98.8), and 0.7 (0.7, 0.8), respectively, at 6 months.</p> <p>Conclusions</p> <p>The function of the injured kidney was preserved in all patients, indicating the efficacy of AE for the treatment of grade-4 blunt renal trauma.</p

Is the combination therapy of IKr-channel blocker and left stellate ganglion block effective for intractable ventricular arrhythmia in a cardiopulmonary arrest patient?

Background: We have previously reported that the defibrillation success rate of intravenous nifekalant hydrochloride (NIF), a pure IKr-channel (IKr: the rapid components of the delayed rectifier potassium current) blocker, was more than 75% for lidocaine-resistant ventricular tachycardia and fibrillation (VT/VF) in patients with out-of-hospital cardiopulmonary arrest (CPA). However, there was no effective treatment for the remaining 25% of patients in whom defibrillation was unsuccessful. We hypothesised that the combination therapy of NIF and left stellate ganglion block (LSGB) was useful for defibrillation in NIF-resistant VT/VF and investigated its efficacy in a retrospective study. Methods and results: We investigated sequentially 272 out-of-hospital CPA patients treated at Tokai University between April and December 2006. VT/VF occurred in 55 patients on arrival or during cardiopulmonary resuscitation (CPR). On the basis of our CPR algorithm, NIF was administered (0.15-0.3 mg/kg, i.v.) after the first direct-current cardioversion. NIF-resistant VT/VFs were observed in 15 out of 55 patients and LSGB was performed on 11 of these with administration of NIF. Sinus rhythm was restored in 7 patients following LSGB (64%) and complete recovery was achieved in 2 patients. In the non-LSGB group, however, all the patients died. Conclusions: The combination therapy of intravenous NIF and LSGB was useful for defibrillation in intractable VT/VF. It is a potential and innovative treatment strategy for IKr-channel blocker resistant VT/VF. (Cardiol J 2007; 14: 355-365

Skuteczność terapii złożonej polegającej na podaniu blokera kanału IKr oraz wykonaniu blokady zwoju gwiaździstego w leczeniu opornych arytmii komorowych u chorych z zatrzymaniem krążenia

Wstęp: W poprzednich doniesieniach autorzy niniejszej pracy dowiedli, że współczynnik skuteczności defibrylacji przy jednoczesnym dożylnym podaniu chlorowodorku nifekalantu (NIF) - selektywnego blokera kanałów szybkiej składowej opóźnionego prostującego prądu potasowego (IKr) wynosił powyżej 75% dla opornego na lignokainę częstoskurczu lub migotania komór (VT/VF) w przebiegu pozaszpitalnego zatrzymania krążenia (CPA). Jednakże dla pozostałych 25% chorych, u których wykonana defibrylacja okazała się nieskuteczna, nie znaleziono efektywnych metod leczenia. Autorzy niniejszej pracy sugerują, że zastosowanie złożonej terapii polegającej na dożylnym podaniu NIF oraz wykonaniu blokady lewego zwoju gwiaździstego (LSGB) jest użyteczne w przypadku defibrylacji VT/VF opornego na działanie NIF. Na podstawie własnych badań retrospektywnych podjęto także próbę oceny skuteczności tej terapii. Metody i wyniki: Do badania włączono kolejnych 272 chorych przyjętych do Kliniki Kardiologii Uniwersytetu Tokai w okresie od kwietnia do grudnia 2006 roku z powodu pozaszpitalnego zatrzymania krążenia. U 55 pacjentów (podczas przyjęcia lub też w przebiegu resuscytacji krążeniowo-oddechowej) stwierdzono VT/VF. Zgodnie z samodzielnie wypracowanymi przez autorów pracy algorytmami prowadzenia resuscytacji krążeniowo-oddechowej NIF (w dawce 0,15-0,3 mg/kg) podawano dożylnie po pierwszej próbie kardiowersji. Oporne na działanie NIF częstoskurcze komorowe/migotania komór wystąpiły u 15 spośród 55 pacjentów. U 11 chorych z powyższej grupy wykonano LSGB oraz podano dożylnie NIF. U 7 osób (64%) po zabiegu LSGB uzyskano powrót rytmu zatokowego. Całkowity powrót do zdrowia zanotowano u 2 chorych. Jednakże w grupie, w której nie wykonano zabiegu blokady lewego zwoju gwiaździstego (grupa nie-LSBG), zmarli wszyscy pacjenci. Wnioski: Terapia złożona polegająca na dożylnym podaniu NIF oraz wykonaniu LSGB okazała się użyteczna w przypadku defibrylacji opornego VT/VF. Jest to potencjalna i innowacyjna strategia leczenia opornego na selektywne blokery kanałów IKr częstoskurczu komorowego/ migotania komór. (Folia Cardiologica Excerpta 2007; 2: 524-536

The prehospital quick SOFA score is associated with in-hospital mortality in noninfected patients: A retrospective, cross-sectional study.

This study aimed to determine the accuracy of the quick Sequential Organ Failure Assessment (qSOFA) score in predicting mortality among prehospital patients with and without infection. This single-center, retrospective, cross-sectional study was conducted among patients who arrived via the emergency medical services (EMS). We calculated the qSOFA score and Modified Early Warning Score (MEWS) from prehospital records. We identified patients as infected if they received intravenous antibiotics at the emergency department or within the first 24 hours. Receiver operating characteristic analysis was used to evaluate and compare the performance of the qSOFA score, each physiological parameter, and the MEWS in predicting admission and in-hospital mortality in patients with and without infection. Multivariate analysis was used to evaluate the qSOFA score and other risk factors. Out of 1574 prehospital patients, 47.1% were admitted and 3.2% died in the hospital. The performance of the qSOFA score in predicting in-hospital mortality in noninfected patients was 0.70, higher than for each parameter and the MEWS. The areas under the curve for the qSOFA+ model vs. the qSOFA- model was 0.77 vs. 0.68 for noninfected patients (p <0.05) and 0.71 vs. 0.68 for infected patients (p = 0.41). The likelihood ratio test comparing the qSOFA- and qSOFA+ groups demonstrated significant improvement for noninfected patients (p <0.01). Multivariate regression analysis for in-hospital mortality demonstrated that the qSOFA score is an independent prognosticator for in-hospital mortality, especially among noninfected patients (odds ratio, 3.60; p <0.01). In conclusion, the prehospital qSOFA score was associated with in-hospital mortality in noninfected patients and may be a beneficial tool for identifying deteriorating patients in the prehospital setting

Current strategy for hollow viscus injury with active bleeding: A case report

Despite rapid advancements in medical technologies, the use of interventional radiology in a patient with hemodynamic instability or hollow viscus injury remains controversial. Here, we discuss important aspects regarding the use of interventional radiology for such patients. A 74-year-old Japanese male climber was injured following a 10 m fall. On admission, his systolic blood pressure was 40 mmHg. He had disturbance of consciousness and mild upper abdominal pain without peritoneal irritation. Focused assessment sonography for trauma indicated massive hemorrhage in the intra-abdominal cavity. Plain radiographs revealed hemopneumothorax with right-side rib fractures. Thoracostomy to the right thoracic cavity and massive transfusion were immediately performed. Consequently, a sheath catheter was inserted into the common femoral artery for interventional radiology. His systolic blood pressure increased to 80 mmHg owing to rapid transfusion. In the computed tomography scan room, based on computed tomography findings, we judged that it was possible to achieve hemostasis by interventional radiology. The time from hospital admission to entering the angiography suite was 38 min. Transcatheter arterial embolization for hemorrhage control was performed without complications. Following transcatheter arterial embolization, he was admitted to the intensive care unit. All injuries could be treated conservatively without surgery. His post-interventional course was uneventful, and he recovered completely after rehabilitation. Hemorrhage control using interventional radiology should be assessed as a first-line treatment, even in hemodynamically unstable patients having a hollow viscus injury with active bleeding, without obvious findings that indicate surgical repair