Fatal vascular complications during transradial percutaneous coronary intervention: A case report.

RATIONALE: Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the tract of the wire or catheter can be injured at any point, causing various types of bleeding complications. PATIENT CONCERNS: A 57-year-old man visited due to chest discomfort. Coronary angiography showed significant stenosis at the distal right coronary artery (RCA). Immediately after the coronary guidewire was passed through the distal RCA, he started a vigorous cough. The voice changed, dyspnea occurred within minutes, and lip cyanosis and stridor were observed. After endotracheal intubation, successful stenting of the distal RCA was achieved. He was extubated at 30 minutes after coronary stenting, but 1-hour post-extubation, his blood pressure suddenly decreased to 70/50 mmHg. DIAGNOSIS: Mediastinal widening was newly noted on chest X-ray, and blood hemoglobin was decreased. Contrast-enhanced chest computed tomography showed mediastinal hematoma, tracheal compression, and hemothorax. Contrast extravasation was noted in the terminal branches of the inferior thyroid artery on brachiocephalic angiography. INTERVENTIONS: Successful hemostasis was achieved with endovascular embolization therapy using a Tornado embolization microcoil, Gelfoam gelatin sponge, and Histoacryl glue. The next day, the mediastinal hemorrhage was drained by mediastinoscopy. The endotracheal intubation and ventilator care were maintained for 2 days, and 6 units of packed red blood cells were transfused. Antithrombotics were used to prevent stent thrombosis, and antibiotics to control infection, respectively. OUTCOMES: After successful hemostasis, thrombocytosis and high on-treatment platelet reactivity that disappeared at 2 weeks post-discharge were noted. Follow-up chest imaging showed the normalized mediastinal widening. At 14 months post-discharge, the patient remains healthy. LESSONS: As life-threating vascular complications, such as brachiocephalic, subclavian vessel dissection, and vessel perforation in the internal mammary, costocervical, and thyrocervical arteries, can occur anytime during transradial PCI, the intervention cardiologist should be well aware of it and have the appropriate countermeasures implemented in the routine procedure.

Application of lidocaine jelly on chest tubes to reduce pain caused by drainage catheter after coronary artery bypass surgery.

The objective of this study was to assess the effect of lidocaine jelly application to chest tubes on the intensity and duration of overall pain, chest tube site pain and the required analgesics for postoperative pain relief in coronary artery bypass graft (CABG) patients. For patients in group L, we applied sterile 2% lidocaine jelly on the chest tubes just before insertion, and for patients in group C, we applied normal saline. Overall visual analogue scale (VAS), maximal pain area with their VAS were documented postoperatively, and the frequency that button of patient-controlled analgesia was pressed (FPB) and total fentanyl consumption were assessed. The number of patients who complained that tube site was the most painful site was significantly higher in group C than in group L (85% vs. 30% at extubation, P<0.001). The overall VAS score was significantly higher in group C than in group L (39.14±12.49 vs. 27.74±13.76 at extubation, P=0.006). After all of the tubes were removed, the VAS score decreased more in group C (5.74±4.77, P<0.001) than in group L (3.05±2.48, P<0.001). FPB and total fentanyl consumption were significantly higher in group C than in group L (73.00, 59.00-78.00 vs. 34.00, 31.00-39.25, P<0.001; 2,214.65±37.01 vs. 1,720.19±361.63, P<0.001, respectively). Lidocaine jelly application is a very simple way to reduce postoperative pain by reducing chest tube site pain after CABG. (Clinical Trials Registry No. ACTRN 12611001215910).

Hemolytic anemia case caused by an inverted inner felt after bentall operation.

A 26-yr-old male patient reported worsened dyspnea, dizziness one year after an emergency Bentall operation for type A aortic dissection. There was evidence of hemolytic anemia and aortogram revealed a significant stenosis at the distal anastomosis site. During the reoperation, we found the inner felt at the distal anastomosis was inverted causing a significant stenosis. The reoperation successfully resolved this problem. Here, we report a rare case of hemolytic anemia caused by an inverted inner felt after Bentall operation.

A case of giant, benign schwannoma associated with total lung collapse by bloody effusion.

Benign schwannoma is the most common neurogenic tumor in the mediastinum. Mediastinal benign schwannomas are most often asymptomatic and rarely accompanied by bloody pleural effusion. In the clinical analysis of 7 cases of pulmonary schwannomas, pleural effusion, and blood invasion were evident in 3 patients with malignant schwannoma. Herein, we report a rare case of giant, benign schwannoma presented with total collapse of right lung by massive, bloody pleural effusion.

Acute eosinophilic pneumonia leading to acute respiratory failure in a current systemic corticosteroid user.

A 69-year-old female patient visited the emergency room with fever (38.3℃) and dyspnea. She had been taking prednisolone (5 mg once per day) and methotrexate (2.5 mg once per week) for rheumatoid arthritis for 2 years. Chest computed tomography (CT) showed bilateral, multifocal ground glass opacity with interlobular septal thickening. Peripheral blood leukocyte count was 6,520/mm(3) (neutrophils, 77.4%; eosinophils, 12.1%). During the night, mechanical ventilation was initiated due to the development of severe hypoxemia. Bronchoalveolar lavage fluid showed a high proportion of eosinophils (49%). Her symptoms improved dramatically after commencement of intravenous methylprednisolone therapy. This is the first report of idiopathic acute eosinophilic pneumonia developing in a current user of systemic corticosteroids.

Omental infarction: case series and review of the literature.

BACKGROUND: Omental infarction is a rare disease entity that can cause acute or subacute abdominal pain. In the past, it was thought that omental infarction mainly occurred on the right side because it was detected when surgery was performed on patients who complained of abdominal pain on the right side. OBJECTIVE: We present this case to demonstrate that omental infarction can occur at any site, including the epigastric area and the lower abdomen, and even on the left side where the greater omentum is located. CASE REPORT: Four patients with omental infarction presented to the Emergency Department with various clinical symptoms. All of them were diagnosed by computed tomography scan. Omental infarction occurred on the right side in 2 patients, at the epigastric area in 1 patient, and on the left side in 1 patient. Three were improved with supportive care. Laparoscopy was performed in 1 patient because his abdominal pain persisted despite conservative treatment. CONCLUSION: Omental infarction should be included in the differential diagnosis list of acute abdominal pain because it can occur at any site. In addition, because this disease runs a self-limited course, conservative care is recommended. Thus, unnecessary operations can be avoided in cases where omental infarction is diagnosed by imaging studies.

Fulminant myocarditis managed with pulsatile extracorporeal life support; use of Twin Pulse Life support (T-PLS®).

Fulminant myocarditis frequently results in severe hemodynamic deterioration. High-dose vasopressors or sometimes mechanical circulatory support are required. We report on two cases of fulminant myocarditis successfully treated with pulsatile extracorporeal life support (T-PLS®, Twin Pulse Life support, New heart bio.BHK, Seoul, Korea). With T-PLS, we were able to provide mechanical support to patients until they recovered completely.

The effects of barrier materials on reduction of pericardial adhesion formation in rabbits: a comparative study of a hyaluronan-based solution and a temperature sensitive poloxamer solution/gel material.

OBJECTIVE: This study was performed to examine the efficacy and safety of a hyaluronan solution (Guardix-SL) and a temperature sensitive poloxamer solution/gel material (Guardix-SG) on the prevention of pericardial adhesion in rabbits. METHODS: A total of 60 rabbits were divided into three groups according to material applied after epicardial abrasion: the control group (group CO), the Guardix SL group (group SL), and the Guardix SG group (group SG). The ejection fraction and the presence of pericardial effusion were evaluated by echocardiograms at the immediate postoperative period and 2 wk after the surgery. The adhesion was evaluated macroscopically and microscopically 2 wk after the surgery. RESULTS: In the group SG, mild pericardial effusions were observed only at the immediate postoperative period in 10 out of 20 rabbits with an insignificant reduction of the ejection fraction. Group CO had a significantly higher macroscopic adhesion and fibrosis score than did groups SL and SG (P < 0.001), and group SL had a significantly higher adhesion score than did group SG (P = 0.045). Inflammation score and the expression of anti-macrophage antibody in group CO were higher than those in groups SL and SG, although the differences were not significant. CONCLUSIONS: Guardix-SL and Guardix-SG effectively reduced the adhesion formation, and Guardix-SG is more effective than Guardix-SL for preventing adhesion. However, Guardix-SG showed a potential disadvantage of decreasing the ejection fraction, although this was statistically insignificant. Further study to verify the appropriate dosage to maximize the therapeutic effect without decreasing the heart function is needed.

Elevated serum S100B levels in acute spinal fracture without head injury.

BACKGROUND: S100B is a biomarker that reflects injury to the central nervous system. As the spine is an integral part of the spinal cord, a study was undertaken to investigate whether serum S100B levels are associated with acute spinal fracture without head injury. METHODS: The study population consisted of 32 consecutive patients aged > or = 18 years in whom the emergency physicians suspected spinal fractures. All the patients underwent CT scans to establish the diagnosis of spinal fracture. MRI was then performed on all the patients to determine the presence of spinal cord injury. RESULTS: Serum S100B levels were higher in the spinal fracture group than in the non-spinal fracture group, and 19 of the 20 patients in the spinal fracture group (95%) had an S100B level >0.12 microg/l, whereas all 12 of the non-spinal fracture group had an S100B level < or = 0.12 microg/l. The S100B level in patients with epidural encroachment of the spinal cord was significantly higher (0.22-4.58 microg/l; mean 2.45 microg/l; 95% CI 0.95 to 3.94) than in those without epidural encroachment (0.114-2.87 microg/l; mean 0.80 microg/l; 95% CI 0.24 to 1.37) (p=0.037). Plain radiography revealed no definite abnormal findings in half of the patients with spinal fracture. CONCLUSIONS: Serum S100B levels are raised in all patients with acute spinal fracture without head injury. Spinal fracture may therefore be one of the extracerebral sources of S100B. Serum S100B levels may be an effective tool for excluding subtle spinal fractures with no clear radiographic findings.

Localized pulmonary edema in the right upper lobe associated with left atrial myxoma.

Localized pulmonary edema in the right upper lobe has usually been reported in patients with mitral incompetence. Cardiac myxomas that involve the left atrium can cause elevated filling pressure with resultant bilateral or symmetric pulmonary edema. To our knowledge, however, a case of localized pulmonary edema associated with cardiac myxoma has not previously been reported in the literature. We present a case of localized pulmonary edema in the right upper lobe associated with left atrial myxoma.

Kidney rupture after extracorporeal shockwave lithotripsy: report of a case.

BACKGROUND: Complications of extracorporeal shockwave lithotripsy (ESWL) occur in a small number of patients, although serious injury is rare. OBJECTIVE: To report the serious complication of kidney rupture during ESWL. CASE REPORT: A 65-year-old man was transferred to the Emergency Department (ED) with right flank pain. He had undergone ESWL for the right renal stone at a regional hospital 2 days earlier. Flank pain developed immediately after ESWL and was not spontaneously relieved. Computed tomography scan performed at the regional hospital showed an extensive right perinephric hematoma. When the patient arrived at the ED, his vital signs were unstable but were stabilized with fluid resuscitation and transfusion. Conservative care with no nephrectomy was chosen because there was no evidence of active bleeding on Doppler ultrasound examination. He was uneventfully discharged on the 31st hospital day without further complications. CONCLUSION: Although it is rare, patients may present with kidney rupture or hypotension after ESWL.

Effects of audio tone guidance on performance of CPR in simulated cardiac arrest with an advanced airway.

THE AIM OF THE STUDY: Despite the emphasis of cardiopulmonary resuscitation (CPR) quality, the performance of on-site CPR is reported to be frequently unsuccessful. In order to improve CPR quality, various feedback systems have been developed, but they have not yet been widely used on site due to low economic efficiency. The present study was attempted to determine whether CPR quality can be improved using audio tone guidance. THE METHODS: A total of 80 seniors at our medical school and college of nursing participated in the study. After they were trained in CPR according to the 2005 guidelines, they performed CPR using a cardiac arrest model with an advanced airway. The participants were organized into 40 groups. After they took Test 1 without any feedback for 2 min, they were randomly assigned to the feedback and control groups and took Test 2 for 2 min. In the feedback group, a low-pitched sound was delivered every 0.6 s for the guidance of chest compression and a high-pitched sound was simultaneously delivered every 10 deliveries of a low-pitched sound for the guidance of ventilation at 6s intervals. THE RESULTS: In the feedback group the mean compression rate significantly improved in accuracy from 111.5+/-13.7/min to 100.1+/-3.2/min (P<0.01), and ventilation counts significantly improved in accuracy from 7.4+/-1.8/min to 9.9+/-0.3/min (P<0.01). However, the mean compression depth significantly decreased from 39.3+/-9.5 mm to 35.8+/-8.2 mm (P<0.01). THE CONCLUSION: Audio tone guidance ensures better chest compression rate and ventilation rate but this does not necessarily result in a better CPR quality.

Minimally invasive concomitant cardiac procedures and repair of pectus excavatum: case report.

A minimally invasive concomitant repair of an atrial-septal defect II with patent ductus arteriosus and pectus excavatum, using a substernal steel bar was successfully done in a 10-year-old girl. Postoperative outcomes and cosmetic appearance were excellent. Therefore, a simultaneous repair of pectus excavatum with cardiac lesions performed in a minimally invasive way is feasible and should be considered, particularly in female children.