Phrenic Arterial Injury Presenting as Delayed Hemothorax Complicating Simple Rib Fracture

Delayed hemothorax after blunt torso injury is rare, but might be associated with significant morbidity and mortality. We present a case of delayed hemothorax bleeding from phrenic artery injury in a 24-year-old woman. The patient suffered from multiple rib fractures on the right side, a right hemopneumothorax, thoracic vertebral injury and a pelvic bone fracture after a fall from a fourth floor window. Delayed hemothorax associated with phrenic artery bleeding, caused by a stab injury from a fractured rib segment, was treated successfully by a minimally invasive thoracoscopic surgery. Here, we have shown that fracture of a lower rib or ribs might be accompanied by delayed massive hemothorax that can be rapidly identified and promptly managed by thoracoscopic means.

The Usefulness of Visual Aids assisted Informed Consent for Central Venous Catheter Insertion with Subclavian Vein

PURPOSE: Informed consent is a basic standard of care for all patients undergoing invasive procedures, but the effectiveness of consent form describing risks of procedures in a way that minimizes anxiety and maximizes recall of information is often poor. This study was designed to compare level of understanding and recall of information between patients receiving visual aid assisted informed consent and those administered written consent only. METHODS: A sample population was randomized into two groups to receive one of two information delivery methods. The intervention group was presented visual aids explaining the procedure. The control group received information from physicians with written consent in the traditional manner. After the education sessions, all participants completed a questionnaire including a 9-question knowledge measurement section and were asked to grade there satisfaction level on 4-point scale. Mean scores, agreement and satisfaction levels were compared to assess whether the informed consent with visual aids was superior to standard written consent. Statistical analysis employed Student's ttest, and the chi-square test with significance levels at a pvalue of <0.05. RESULTS: Of the 100 individuals enrolled, 50 were randomized to the visual aids group. Mean knowledge scores were higher in the visual aids group (76.4+/-11.1) than in the written consent group (50.9+/-15.1, p=0.00), and the visual aid group expressed greater satisfaction with their education than did the written consent group (74.5+/-14.7 versus 49.0+/-20.8, p=0.00). The proportion of agreement was also higher in the visual aid group than in the written consent group (p=0.00). CONCLUSION: The use of visual aids in explaining central venous catheterization yielded higher knowledge scores and satisfaction levels than did traditional written informed consent.

Endoscopic Evaluation of Upper Gastrointestinal Injury in Patients with Noncaustic Drug Ingestion

PURPOSE: There have been few studies of the direct effect of a drug overdose on the gastrointestinal (GI) mucosa. This study evaluated the frequency of GI mucosal injury and the necessity for esophagogastroduodenoscopy (EGD) in patients with non-caustic drug ingestion (DI). METHODS: Patients who presented to the emergency department with non-caustic DI from January 2001 to December 2003 were enrolled in this study. EGD was performed on the patients after acute toxicologic management. Those who did not consent to EGD were excluded. The EGD findings were analyzed according to the non-caustic drug that had been ingested. RESULTS: Among the 37 patients, 24 (65%) had significant endoscopic lesions. Endoscopic findings were gastric erosion (n=17), ulcers (n=5), esophageal erosion (n=1), and a gastric hemorrhage (n=1). Pesticides, rodenticides, salicylates, and high dose doxylamine (>5 g) were associated with drug-induced gastropathy. CONCLUSION: This study suggests that GI mucosal injury has been underestimated in DI patients and that a treatment for gastromucosal protection should be performed when the non-caustic ingested drug is a pesticides, a rodenticides, a salicylates or high-dose doxylamine.

Estimate the Cuff Inflation Volume to Maintain Safe Intracuff Pressure of an Endotracheal Tube

PURPOSE: The cuff of an endotracheal-tube is used to prevent air leak and pulmonary aspiration. Although high cuff pressure may result in mucosal complications, such as tracheal stenosis, endotracheal-tube cuff pressures are not routinely measured in emergency settings in Korea. We designed this study to estimate the cuff inflation volume (Vcuff) required to maintain appropriate intracuff pressure of the endotracheal tube. METHODS: We measured the cuff pressure for adult patients on whom endotracheal intubation was performed in the emergency department. The cuff pressure was measured by using a VBM(R) control inflator, and a Mallinckrodt Hi-Lo(R) endotracheal tube was used. The maximum and the minimum Vcuff were defined as Vcuff, producing a recommended maximum and minimum cuff pressure of 32 and 22 c m H2O, respectively. We performed multiple regression analysis to estimate the maximum Vcuff from age, gender, tube size, neck circumference, artificial ventilation, and peak inflation pressure. RESULTS: The maximum Vcuff was 7.1+/-1.9 ml, and the minimum Vcuff was 5.5+/-1.8 ml, with a difference of 1.6+/- 0.8 ml. The value of Vcuff in male patients were significantly higher than they were in female patients. The following regression equations for maximum Vcuff were calculated: "8.2-2xfemale "for a 7.5-mm tracheal tube and "5.5+0.04 x age-1.7 x female "for a 7.0-mm tube. CONCLUSION: We have proposed equations to calculate the Vcuff for 7.5- and 7.0-mm Mallinckrodt tubes. However, this study suggests that the difference between the maximum and the minimum Vcuff is small, so the routine use of a cuff pressure gauge is required for accurate cuff pressure maintenance.

Usefulness of C-Reactive Protein and Abdominal CT for the Prognosis of Acute Pancreatitis

PURPOSE: An early prediction of the prognosis is essential for proper management of acute pancreatitis. The Ranson criteria, a classic prognostic marker, are known not to provide relevant information, especially in an acute setting. The purpose of this study was to evaluate the usefulness of creactive protein (CRP) and CT scan as prognostic indicators in patients of acute pancreatitis. METHODS: Patients who were diagnosed with acute pancreatitis from January 2002 to December 2003 were enrolled in this study. The patients underwent abdominal CT scans, and their CT findings were classified as normal, pancreatic enlargement, peripancreatic fat infiltration, single peripancreatic fluid collection, and two or more fluid collections or retroperitoneal air. The CRP results were classified as 15 mg/dL. The outcome was evaluated by using the mortality and the number of organ failures. RESULTS: Among the 188 enrolled patients, 6 were died. The CRP level and the CT severity index were significantly lower in the survival group. The number of organ failures was significantly higher when two or more fluid collections were found in the CT and when the CRP level was higher than 15 mg/dL. The most useful indicator to predict death was the CT-CRP determined by using a ROC curve analysis. CONCLUSION: This study suggests that CT-CRP may be used as a prognostic indicator of acute pancreatitis in the emergency department.