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 Adequacy of a Conventional Mechanical Ventilator as a Ventilation Method during Cardiopulmonary Resuscitation: A Manikin Study / 대한중환자의학회지

BACKGROUND: We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR). METHODS: A self-inflating bag resuscitator and a mechanical ventilator were used to test two experimental models: Model 1 (CPR manikin without chest compression) and Model 2 (CPR manikin with chest compression). Model 2 was divided into three subgroups according to ventilator pressure limits (P(limit)). The self-inflating bag resuscitator was set with a ventilation rate of 10 breaths/min with the volume-marked bag-valve procedure. The mode of the mechanical ventilator was set as follows: volume-controlled mandatory ventilation of tidal volume (Vt) 600 mL, an inspiration time of 1.2 seconds, a constant flow pattern, a ventilation rate of 10 breaths/minute, a positive end expiratory pressure of 3 cmH2O and a maximum trigger limit. Peak airway pressure (P(peak)) and Vt were measured by a flow analyzer. Ventilation adequacy was determined at a Vt range of 400-600 mL with a P(peak) of < or = 50 cmH2O. RESULTS: In Model 1, Vt and P(peak) were in the appropriate range in the ventilation equipments. In Model 2, for the self-inflating bag resuscitator, the adequate Vt and P(peak) levels were 17%, and the P(peak) adequacy was 20% and the Vt was 65%. For the mechanical ventilator, the adequate Vt and P(peak) levels were 85%; the P(peak) adequacy was 85%; and the Vt adequacy was 100% at 60 cmH2O of P(limit). CONCLUSIONS: In a manikin model, a mechanical ventilator was superior to self-inflating bag resuscitator for maintaining adequate ventilation during chest compression.

The Adequacy of a Conventional Mechanical Ventilator as a Ventilation Method during Cardiopulmonary Resuscitation: A Manikin Study / 대한구급학회지

BACKGROUND: We conducted this study to verify whether a mechanical ventilator is adequate for cardiopulmonary resuscitation (CPR). METHODS: A self-inflating bag resuscitator and a mechanical ventilator were used to test two experimental models: Model 1 (CPR manikin without chest compression) and Model 2 (CPR manikin with chest compression). Model 2 was divided into three subgroups according to ventilator pressure limits (P(limit)). The self-inflating bag resuscitator was set with a ventilation rate of 10 breaths/min with the volume-marked bag-valve procedure. The mode of the mechanical ventilator was set as follows: volume-controlled mandatory ventilation of tidal volume (Vt) 600 mL, an inspiration time of 1.2 seconds, a constant flow pattern, a ventilation rate of 10 breaths/minute, a positive end expiratory pressure of 3 cmH2O and a maximum trigger limit. Peak airway pressure (P(peak)) and Vt were measured by a flow analyzer. Ventilation adequacy was determined at a Vt range of 400-600 mL with a P(peak) of < or = 50 cmH2O. RESULTS: In Model 1, Vt and P(peak) were in the appropriate range in the ventilation equipments. In Model 2, for the self-inflating bag resuscitator, the adequate Vt and P(peak) levels were 17%, and the P(peak) adequacy was 20% and the Vt was 65%. For the mechanical ventilator, the adequate Vt and P(peak) levels were 85%; the P(peak) adequacy was 85%; and the Vt adequacy was 100% at 60 cmH2O of P(limit). CONCLUSIONS: In a manikin model, a mechanical ventilator was superior to self-inflating bag resuscitator for maintaining adequate ventilation during chest compression.

The Relation between Neurologic Prognosis and Optic Nerve Sheath Diameter Measured in Initial Brain Computed Tomography of Cardiac Arrest and Hanging Patients / 대한구급학회지

BACKGROUND: Early prediction of neurologic outcome is important to patients treated with therapeutic hypothermia after hypoxic brain injury. Hypoxic brain injury patients may have poor neurologic prognosis due to increased intracranial pressure. Increased intracranial pressure can be detected by optic nerve sheath diameter (ONSD) measurement in computed tomography (CT) or ultrasound. In this study, we evaluate the relation between neurologic prognosis and optic nerve sheath diameter measured in brain CT of hypoxic brain injury patients. METHODS: We analyzed the patient clinical data by retrospective chart review. We measured the ONSD in initial brain CT. We also measured and calculated the gray white matter ratio (GWR) in CT scan. We split the patients into two groups based on neurologic outcome, and clinical data, ONSD, and GWR were compared in the two groups. RESULTS: Twenty-four patients were included in this study (age: 52.6 +/- 18.3, 18 males). The mean ONSD of the poor neurologic outcome group was larger than that of the good neurologic outcome group (6.07 mm vs. 5.39 mm, p = 0.003). The GWR of the good neurologic outcome group was larger than that of the poor outcome group (1.09 vs. 1.28, p = 0.000). ONSD was a good predictor of neurologic outcome (area under curve: 0.848), and an ONSD cut off > or = 5.575 mm had a sensitivity of 86.7% and a specificity of 77.8%. CONCLUSIONS: ONSD measured on the initial brain CT scan can predict the neurologic prognosis in cardiac arrest and hanging patients treated with therapeutic hypothermia.

Bedside Ultrasound for the Diagnosis of Bowel Necrosis in a Patient with an Altered Mental Status

Bowel necrosis generally requires an immediate operation and causes a high mortality rate. Unfortunately, in patients with altered consciousness, diagnosis can be very difficult. In our case, a 45-year-old male, with an altered mentality due to brain injury (from head trauma) and alcohol intoxication, was brought into our emergency department. Due to his altered state, he had no initial complaints about any other symptoms besides a headache. After a physical examination, no other signs were observed, except for swelling on the head. However, a worsening of wide anion gap metabolic acidosis was observed upon laboratory examination. A bedside ultrasound was performed to evaluate the reason for this metabolic acidosis, and pneumatosis intestinalis and hepatic portal venous gas was observed. Eventually bowel necrosis was diagnosed, an emergency operation was executed, and the patient recovered.