Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

Clinical Guidance for Point-of-Care Ultrasound in the Emergency and Critical Care Areas after Implementing Insurance Coverage in Korea

Point-of-care ultrasound (POCUS) is a useful tool that is widely used in the emergency and intensive care areas. In Korea, insurance coverage of ultrasound examination has been gradually expanding in accordance with measures to enhance Korean National Insurance Coverage since 2017 to 2021, and which will continue until 2021. Full coverage of health insurance for POCUS in the emergency and critical care areas was implemented in July 2019. The National Health Insurance Act classified POCUS as a single or multiple-targeted ultrasound examination (STU vs. MTU). STU scans are conducted of one organ at a time, while MTU includes scanning of multiple organs simultaneously to determine each clinical situation. POCUS can be performed even if a diagnostic ultrasound examination is conducted, based on the physician's decision. However, the Health Insurance Review and Assessment Service plans to monitor the prescription status of whether the POCUS and diagnostic ultrasound examinations are prescribed simultaneously and repeatedly. Additionally, MTU is allowed only in cases of trauma, cardiac arrest, shock, chest pain, and dyspnea and should be performed by a qualified physician. Although physicians should scan all parts of the chest, heart, and abdomen when they prescribe MTU, they are not required to record all findings in the medical record. Therefore, appropriate prescription, application, and recording of POCUS are needed to enhance the quality of patient care and avoid unnecessary cut of medical budget spending. The present article provides background and clinical guidance for POCUS based on the implementation of full health insurance coverage for POCUS that began in July 2019 in Korea.

External validation of STONE score and modified STONE score

OBJECTIVE@#The STONE score and modified STONE score are useful clinical prediction rules for ureteral calculi. This study performed an external validation of the STONE score and modified STONE score. The purpose of this study was to minimize the economic cost and radiation exposure of computed tomography.@*METHODS@#The electronic medical records of patients complaining of flank pain from January 2016 to December 2017 at a single emergency department were reviewed retrospectively. The patients were classified into three groups according to the STONE score and modified STONE score. The prevalence of urethral calculi and other important alternative diagnoses were calculated in each group.@*RESULTS@#Out of 561 patients, 266 patients were enrolled in this study, and 222 patients (83.5%) had a ureteral calculus. The same 266 patients were compared using the two clinical decision rule, STONE score, and the modified STONE score. The patients were classified into three groups. The prevalence of ureteral stones in the STONE score was 18.8% in the low-score group, 81.7% in the moderate-score group, and 91.1% in the high-score group. The prevalence of the modified STONE score was 20.0% in the low-score group, 54.1% in the moderate-score group, and 93.0% in the highscore group. The area under the curve of the modified STONE score was 0.779 higher than the area under the STONE score curve 0.73.@*CONCLUSION@#The modified STONE score has superior diagnostic specificity to the STONE score.

The Effects of Work Performance, Perceived Organizational Support and Personal Coping Resources on Job Satisfaction among Infusion Nurses in Korea / 한국간호교육학회지

PURPOSE: This study is a descriptive study to explore the effects of work performance, perceived organization support, and personal coping resources on job satisfaction of infusion nurses in Korea. METHODS: The participants of this study were 155 infusion nurses in 19 general hospitals and advanced general hospitals in Korea. Data were collected from January to March 2018 using a structured questionnaire and analyzed with the SPSS software version 23. RESULTS: The participants' job satisfaction score was 3.01, their work performance score was 3.60, their perceived organization support score was 2.83, and their personal coping resources score was 3.53. The regression model for job satisfaction was significant (F=56.10, p < .001), and the total explanatory power was 52%. The variables affecting job satisfaction were personal coping resources (β=.44, p < .001), perceived organization support (β=.42, p < .001), and working locations (β=.13, p=.028). CONCLUSION: To increase job satisfaction of infusion nurses, boosting strategies for personal coping resources, perceived organization support, and examination of work performance characteristics of each local area should be considered. In addition, development of customized programs is needed, focusing on infusion nurse personnel and job characteristics.

Confirmation of the Relation between Femoral Artery and Vein for Central Venous Cannulation: A Prospective Investigation Using Ultrasound

PURPOSE: Femoral vein catheterization is often performed using a landmark technique, despite the recommended method of using ultrasound guidance. Although the landmark-based procedure is a well-known, widely adopted method to date, there are insufficient studies validating the effectiveness of this method. Hence, the purpose of this study was to confirm the relationship between femoral artery and vein using an ultrasound, as well as to validate the effectiveness of the femoral vein catheterization method using the landmark technique. METHODS: This was a prospective, repeated measurement study. Using an ultrasound with a 10 MHz transducer, the femoral vein cross-sectional areas on the right side were saved at a distance of 1, 2, 3, and 4 cm from the inguinal ligament with supine and hip abduction-external rotation positions. The width of the femoral vessels, center-to-center distance between the femoral artery and vein(horizontal distance between the center of the femoral artery and vein) and width of exposed femoral vein (not posterior to femoral artery) were measured. RESULTS: The width of the femoral vein, the center-to-center distance between the femoral artery and vein, as well as the width of the exposed femoral vein were significantly decreased as the distance from the inguinal ligament was increased, regardless of the posture change (p<0.001). However, at a distance of 1 cm from the inguinal ligament, only 5.4% of the femoral veins were exposed without disturbance of the femoral artery, and there were also a few cases in which the femoral veins were not exposed at all. CONCLUSION: It appears that an ultrasound-guided femoral vein catheterization is recommended over the conventional landmark technique.

Bacterial Contamination and Disinfection Status of Laryngoscopes Stored in Emergency Crash Carts / 예방의학회지

OBJECTIVES: To identify bacterial contamination rates of laryngoscope blades and handles stored in emergency crash carts by hospital and area according to the frequency of intubation attempts. METHODS: One hundred forty-eight handles and 71 blades deemed ready for patient use from two tertiary hospitals were sampled with sterile swabs using a standardized rolling technique. Samples were considered negative (not contaminated) if no colonies were present on the blood agar plate after an 18-hour incubation period. Samples were stratified by hospital and according to the frequency of intubation attempts (10 attempts per year) using the χ2-test and Fisher exact test. RESULTS: One or more species of bacteria were isolated from 4 (5.6%) handle tops, 20 (28.2%) handles with knurled surfaces, and 27 (18.2%) blades. No significant differences were found in microbial contamination levels on the handle tops and blades between the two hospitals and two areas according to the frequency of intubation attempts. However, significant differences were found between the two hospitals and two areas in the level of microbial contamination on the handles with knurled surfaces (p<0.05). CONCLUSIONS: Protocols and policies must be reviewed to standardize procedures to clean and disinfect laryngoscope blades and handles; handles should be re-designed to eliminate points of contact with the blade; and single-use, one-piece laryngoscopes should be introduced.

Comparison of Tracheal Intubation Using the Macintosh Laryngoscope Versus the Disposable Laryngoscope by Inexperienced Personnel: A Manikin Study

PURPOSE: Disposable one piece laryngoscope (DOL), which probably carries a lower risk of infection than conventional reusable ones, is the only device which has received approval by the Korean Ministry of Food and Drug safety. In the current study, we evaluated the effectiveness and usefulness of the conventional Macintosh laryngoscope (MAC) and DOL in inexperienced personnel. METHODS: A randomized crossover trial was designed. Ninety seven participants (Medical students, Paramedic students) were enrolled and performed endotracheal intubation with MAC and DOL in Manikin (SimMan(R) Laedal Medical Corporation, Stravanger; Norway). Cormack-Lehane grade, the number of attempts, time required for intubation, and dental compression were measured to evaluate the effectiveness. The participants were given a questionnaire survey on the usefulness of laryngoscopes (easier to use, lightness, brightness, manageable to use, delivering power, safer for patients, intense to use). RESULTS: Regarding the aspect of effectiveness, a significant difference in dental compression was observed between DOL and MAC (p=0.011). Others showed no significant differences. Regarding the aspect of usefulness, DOL was superior to MAC except in delivering power. CONCLUSION: The DOL appears to be a reasonable device for use in emergency airway management. It should be verified for effectiveness and usefulness of newly developed equipment in emergency airway management because it is directly related to life.

The Comparison of Ultrasound Guided Cricothyroid Membrane Identification Method and Anatomical Landmark Palpation Cricothyroid Membrane Identification Method in Intubated Patients

PURPOSE: Cricothyroidotomy had a high failure rate. Ultrasound-guided cricothyroid membrane (CTM) identification may be more accurate and easier than anatomical landmark palpation. The purpose of this study was to compare the accuracy of ultrasound-guided CTM identification method (ultrasound method) and anatomical landmark palpation CTM identification method (palpation method) in patients who were intubated in an emergency medical center. METHODS: Using fluorescent invisible ink, the emergency physician was asked to mark the center of the CTM with the patient by palpation method. After 5 minutes, the participant found the CTM using the ultrasound method and drew a cross with a blue pen. An emergency medicine specialist or senior resident identified the actual center of the CTM with ultrasound and drew a cross with a black pen. The distance between the actual and estimated center of the CTM was measured. Participants measured the ease of use of each method using a 0~10 visual analog scale (VAS). RESULTS: Nineteen patients were enrolled and 38 tests were performed. Both first and second year emergency medicine residents showed that identifying the CTM was more difficult in cases of using the palpation method compared with the ultrasound method. VAS score was 3.0 (1.0-5.0) and 4.0 (2.0-8.0), respectively (p=0.006). Using the ultrasound method and another method, the horizontal length differences were 1.0 mm (IQR 0-2.0) vs. 2 mm (IQR 1.0-3.0) (p<0.001) and the vertical length differences were 1.5 mm (IQR 0-2.0) vs. 3.0 mm (IQR 1.0-9.3), respectively (p<0.001). CONCLUSION: Using the ultrasound method is an easier and more accurate way to find the center of the CTM compared with the palpation method in patients who were intubated in an emergency medical center.

Cervical Epidural Hematoma Following a Facet Joint Nerve Block

Facet joint nerve blocks is the most commonly utilized interventions in managing chronic spinal pain. A fluoroscopically directed facet joint nerve block for pain management may result in a rare complication of spinal epidural hematoma causing acute myelopathy. Although this complication is well-known with epidural anesthesia (where it is usually seen with impaired hemostasis), there are surprisingly few case reports of epidural hematoma after a facet joint nerve block. We report here a case of a 58-year-old man, with no evidence of coagulopathy and not taking antiplatelet medication, having a sudden onset of acute cervical myelopathy from a large cervical epidural hematoma one hour after a facet joint nerve block. Following prompt surgical evacuation of the clot, the patient made a nearly complete recovery. Spinal epidural hematoma after spinal puncture is usually associated with impaired hemostasis. However, this case illustrates that it may occur in the absence of known risk factors. The delayed onset and the absence of risk factors have implications for the use of this procedure in chronic pain management.

The Position of Patients for Safe Central Venous Catheterization Via the Internal Jugular Vein: Prospective Observational Study of Critically Ill Patients

PURPOSE: Carotid artery injuries are common complications during catheterization of the internal jugular vein. To increase successful catheterization, the best position for the reduction of carotid artery injuries was determined. Unlike a previous study, only critically ill patients who needed central venous catheterization in an emergency medical center were included. Three maneuvers were evaluated: Trendelenburg position, head rotation, and adjustments according to ultrasound probe level. METHODS: Eight positions were tested in each patient. The positions were classified by maneuver and ultrasound images of each position were stored. Two factors were determined at each position: "safety width" (the part of the internal jugular vein that did not overlap with the carotid artery) and "overlap width" (the part of the internal jugular vein that did overlap with the carotid artery). RESULTS: Compared with the neutral bed position, safety widths were significantly larger in the Trendelenburg position, and there were no statistical difference in overlap widths. Compared with the non-head rotation position, safety widths were smaller and overlap widths were significantly larger in the 45degrees head rotation positions. Safety widths did-not statistically change safter adjustments for ultrasound probe level. However, changing the ultrasound probe level from the base of Sedillot's triangle to thyroid cartilage significantly decreased overlap widths. Overall, The group of Trendeleberg position, with non-head rotation, whose ultrasound probe level was thyroid cartilage had largest safety widths among 8 groups. CONCLUSION: Among the eight positions tested, the Trendelenburg position (with limited head rotation and adjustments for ultrasound probe level) can reduce carotid artery injuries and increase the successful catheterization of the jugular vein in critically ill patients.

The Position of Patients for Safe Central Venous Catheterization Via the Internal Jugular Vein: Prospective Observational Study of Critically Ill Patients

PURPOSE: Carotid artery injuries are common complications during catheterization of the internal jugular vein. To increase successful catheterization, the best position for the reduction of carotid artery injuries was determined. Unlike a previous study, only critically ill patients who needed central venous catheterization in an emergency medical center were included. Three maneuvers were evaluated: Trendelenburg position, head rotation, and adjustments according to ultrasound probe level. METHODS: Eight positions were tested in each patient. The positions were classified by maneuver and ultrasound images of each position were stored. Two factors were determined at each position: "safety width" (the part of the internal jugular vein that did not overlap with the carotid artery) and "overlap width" (the part of the internal jugular vein that did overlap with the carotid artery). RESULTS: Compared with the neutral bed position, safety widths were significantly larger in the Trendelenburg position, and there were no statistical difference in overlap widths. Compared with the non-head rotation position, safety widths were smaller and overlap widths were significantly larger in the 45degrees head rotation positions. Safety widths did-not statistically change safter adjustments for ultrasound probe level. However, changing the ultrasound probe level from the base of Sedillot's triangle to thyroid cartilage significantly decreased overlap widths. Overall, The group of Trendeleberg position, with non-head rotation, whose ultrasound probe level was thyroid cartilage had largest safety widths among 8 groups. CONCLUSION: Among the eight positions tested, the Trendelenburg position (with limited head rotation and adjustments for ultrasound probe level) can reduce carotid artery injuries and increase the successful catheterization of the jugular vein in critically ill patients.

Effectiveness of Polydeoxyribonucleotide (PDRN) Material on Murine Subcutaneous Laceration Wounds

PURPOSE: To evaluate the effectiveness of polydeoxyribonucleotide (PDRN) material on murine subcutaneous laceration wounds. METHODS: Subcutaneous laceration wounds were made on the back of mice. The mice were divided into two groups according to method of PDRN applied: Group I (control, general dressing, and management) and Group II (PDRN injection). We evaluated gross findings and histological findings for the groups. RESULTS: A total of 18 mice (9 in the Suture group and 9 with Suture+PDRN) were enrolled. In the mean results of gross finding (5-point Likert scale), the mean gross findings for wounds in the PDRN group were significantly higher than the suture groups on post-operative day 4 and 7 (for day 4, Suture: 2, Suture+PDRN: 3.2; for day 7, Suture: 2.7, Suture+PDRN: 4.2; p<0.05). In the histological analysis of wounds in the Suture+PDRN group after 10 days, re-epithelization and granulation tissue formation were better than the Suture group. In terms of wound-healing grade, re-epithelization and inflammation were not different; however, in the Suture+PDRN group, more granulation tissue formation was noted compared to the Suture group (p<0.05). In addition, the expression of VEGF in the Suture+PDRN group significantly increased compared to the Suture group (Suture: 11170+/-2475, Suture + PDRN: 27243+/-6621, p<0.05). CONCLUSION: The Suture+PDRN group can be used for the early treatment and histological healing of subcutaneous laceration wounds.

Comparison of Airway Ultrasonography and Continuous Waveform Capnography to Confirm Endotracheal Tube Placement in Cardiac Arrest Patients: Prospective Observational Study

PURPOSE: The aim of this study was to assess the accuracy and timeliness of using tracheal ultrasound for examination of endotracheal tube placement in cardiac arrest patients. METHODS: This was a prospective, observational study, conducted at the emergency department of a university teaching hospital. Patients underwent emergency intubation due to cardiac arrest. Airway ultrasonography was performed during emergency intubation with the transducer placed transversely at the trachea over the suprasternal notch. Quantitative waveform capnography was used as the criterion standard for confirmation of tracheal intubation. The main outcome was the timeliness between airway ultrasonography and capnography. RESULTS: A total of 16 patients and 19 intubations were included in the analysis. The endotracheal tube was placed in the trachea in 16 intubations and in the esophagus in three intubations. The overall sensitivity and specificity of ultrasound for confirmation of tracheal intubation was 100%, respectively. The capnography application time after intubation was 17.5(10.0~32.5) seconds. The capnograpny confirmation time after application was 30(10~120) seconds. The ultrasound confirmation time for endotracheal tube placement after application was 5(4~5) seconds. CONCLUSION: When patients were in a low pulmonary blood flow state, such as cardiac arrest, capnography confirmation of endotracheal tube placement was not rapid and needed a lot of times. Ultrasound confirmation was very rapid and accurate, and was not affected by pulmonary blood flow. Ultrasound confirmation of endotracheal tube placement is more useful in the emergency department.

Application of a Loss of Resistance Syringe for Obtaining the Adequate Cuff Pressures of Endotracheal Intubated Patients in an Emergency Department

PURPOSE: The endotracheal tube cuff pressure must be kept within the optimal range. This study compared the usefulness of the conventional pilot balloon palpation technique using a 10 cc disposable syringe and passive release technique using a Loss of Resistance (LOR) syringe for obtaining adequate intracuff pressures of endotracheal intubated patients in an emergency department. METHODS: This was a prospective, observational study, conducted at the emergency department of a university teaching hospital. Patients who required endotracheal intubation in an emergency department were enrolled in this study. The patients were divided into two groups: one group who underwent the pilot balloon palpation technique using a conventional syringe (group A, n=40) and the other group who underwent the passive release technique using a LOR syringe technique (group B, n=40). The amount of air that infused into the cuff and the cuff pressure were measured. RESULTS: The mean cuff pressures of groups A and B were 41.0+/-23.7 cmH2O and 23.7+/-16.5 cmH2O, respectively. The mean cuff pressure of group A were significantly higher than group B (p=0.002). The mean air volume that infused into the cuff of groups A and B were 8.6+/-2.6 ml and 7.6+/-2.4 ml, respectively, showing no significant difference (p=0.688). The proportion of the optimal cuff pressure (Normal range: 22-32 cmH2O) of group A (9/40, 22.5%) was higher than that of group B (3/40, 7.5%). CONCLUSION: The range of air volumes and pressures for cuff inflation varied and it may not be possible to obtain the appropriate pressure using the LOR syringe technique. The endotracheal tube cuff pressure must be kept within the optimal range using a pressure monitor control inflator.

Comparison of Adverse Events and Satisfaction between IV and IM Routes for Ketamine Sedation in Pediatric Facial Laceration Repair in the Emergency Department

PURPOSE: The purpose of this study is to compare adverse events and satisfaction of physician, nurse, and parent with intravenous (IV) versus intramuscular (IM) ketamine procedural sedation and analgesia for repair of pediatric facial laceration in the emergency department (ED). METHODS: Pediatric patients aged 1~5 years receiving ketamine for repair of facial laceration were enrolled in a prospective, randomized, controlled trial in the ED. All patients were initially randomized to receive ketamine either 2 mg/kg IV or 4 mg/kg IM. In this study, the primary outcomes were adverse events and length of sedation. The secondary outcomes were satisfaction of physician, nurse, and parent. RESULTS: A total of 78 patients were randomized (39 IV group, 39 IM group), and 76 patients, aged 1 to 5 years, completed the study; 37 IV group and 39 IM group. Vomiting in the ED was more common in the IM group (20.5% versus 2.7%; OR 9.29; 95% CI 1.1 to 78.46). Groan in the ED was less common in the IM group (10.3% versus 35.1%; OR 0.21; 95% CI 0.06 to 0.73). Other adverse events were similar between groups. The number of sedations attempted was higher in the IV group (mean 1.11 versus 1; p=.036). Length of sedation was significantly longer in the IM group (median 59 versus 27 minutes; p=.000). Satisfaction of physician and nurse was higher in the IM group (median 4 versus 4; p=.005 in physicians, 4 versus 2; p=.000 in nurses, Mann Whitney U test). Satisfaction of parent was similar between groups. CONCLUSION: In this study of ketamine sedation for repair of pediatric facial laceration, we found that ketamine 4 mg/kg IM was more effective than 2 mg/kg IV in providing adequate sedation and higher satisfaction of physician and nurse.

Angiomyolipoma Rupture and Spontaneous Pneumothorax in Tuberous Sclerosis Patients: A Case Report

Tuberous sclerosis is a genetic multi-system disorder characterized by wide spread hamartomas in several organs. We present the case of a 28-year-old female patient diagnosed with tuberous sclerosis combined with life threatening complication. She developed a peri-renal hemorrhage due to an angiomyolipoma rupture and spontaneous pneumothorax at a time. In order to diagnose and treat this problem, the emergency physician should understand the clinical presentation and complication associated with tuberous sclerosis.

Investigation of Non-analgesic Subcutaneous Suture and Skin Bond in Patients with Deep Facial Lacerations

PURPOSE: To evaluate the effectiveness of non-analgesic subcutaneous suture with an adhesive agent. METHODS: We sutured lacerated wounds with an adhesive agent using a non-analgesic method and measured pain and patient satisfaction. We classified three steps (I: entering the needle, II: pulling the fiber, III: tying) in the suture sequence and evaluated the pain (painfulness, tolerance, painlessness) for each step. RESULTS: Of 276 patients admitted within the period, 111 were enrolled in this study. The mean wound characteristics were 11+/-4 mm (depth) and 23+/-18 mm (length). Overall, 83(75%) patients were sutured without additional analgesics. On a pain scale, all steps were measured at over 90% with respect to tolerance and painlessness. In step II, tolerance (63%) and painfulness (10%) was higher than in the other steps (p<0.05). The mean rate of satisfaction was 4.7 (group 1, 4.8; group 2, 4.6; group, 3; 4.6, group 4, 4.7 (p=0.673). CONCLUSION: Non-analgesic subcutaneous suture with adhesive agent was very effective for patients who were admitted to the emergency department with deep facial lacerations with a length of no more than 2 cm.

Clinical Progression of Segmental Arterial Mediolysis; Renal Infarction and Intra-abdominal Hemorrhage

This article reports a patient with both a renal infarction and acute intra-abdominal hemorrhage secondary to a rare vascular disease, segmental arterial mediolysis. The patient was a 37-year-old male who presented with acute right flank pain. Abdominal and pelvic computerized tomography (CT) showed a right renal infarction. After three days, the right flank pain had diminished but left flank pain began. Visceral angiography revealed a wedge shape perfusion defect at the mid pole of the left kidney, suggesting a left renal infarction but there were no definite perfusion defects at the right kidney. After ten days, the patient complained of abdominal pain and 2 episodes of syncope. Abdominal CT revealed active bleeding from the splenic artery and a large amount of hemoperitoneum. After emergency embolization, the patient's were stabilized. After 28 days, his condition was improved and discharged without complications. The angiographic and laboratory findings were consistent with a diagnosis of segmental arterial mediolysis involving the renal and splenic artery. This is the first case report of clinical progression related to segmental arterial mediolysis requiring emergent coil embolization.

A Massive Pulmonary Embolism with Hemodynamically Unstable Stroke Symptoms

Pulmonary embolisms account for 13~25% of early deaths after stroke. Early diagnosis and appropriate management of thrombolysis are important, however, diagnosis is often difficult, and the consequences for patients can be severe. Echocardiography is useful for evaluation for massive pulmonary embolism, particularly in hemodynamically unstable patients. We report on a case involving a 67-year-old female patient in severe hemodynamic compromise, with an altered mental status and hemiparesis. Findings on brain computerized tomography (CT) showed acute infarction at the left middle cerebral artery territory and transthoracic echocardiography indicated a massive pulmonary embolism. Despite administration of conservative management, the patient died due to a cerebral complication.