Elimination of CT-detected gas bubbles derived from decompression illness with abdominal symptoms after a short hyperbaric oxygen treatment in a monoplace chamber: a case report.

We report the case of a 54-year-old male compressed-air worker with gas bubbles detected by computed tomography (CT). He had complained of strong abdominal pain 30 minutes after decompression after working at a pressure equivalent to 17 meters of sea water for three hours. The initial CT images revealed gas bubbles in the intrahepatic portal vein, pulmonary artery and bilateral femoral vein. After the first hyperbaric oxygen treatment (HBO2 at 2.5 atmospheres absolute/ATA for 150 minutes), no bubbles were detected on repeat CT examination. The patient still exhibited abdominal distension, mild hypesthesia and slight muscle weakness in the upper extremities. Two sessions of U.S. Navy Treatment Table 6 (TT6) were performed on Days 6 and 7 after onset. The patient recovered completely on Day 7. This report describes the important role of CT imaging in evaluating intravascular gas bubbles as well as eliminating the diagnosis of other conditions when divers or compressed-air workers experience uncommon symptoms of decompression illness. In addition, a short treatment table of HBO2 using non-TT6 HBO2 treatment may be useful to reduce gas bubbles and the severity of decompression illness in emergent cases.

A ruptured bronchial artery aneurysm with massive haemoptysis.

Massive haemoptysis is associated with high mortality. Among various diseases presenting with massive haemoptysis, a ruptured bronchial artery aneurysm (BAA) is a rare entity. We report the case of a ruptured BAA as small as 3 mm in diameter associated with massive haemoptysis in a previously healthy 77-year-old woman. She had suddenly developed massive haemoptysis and was intubated and admitted to the intensive care unit. A CT scan and repeated bronchoscopy could not reveal the cause. Because haemorrhage continued, she underwent bronchial arteriography (BAG) twice. We finally detected a BAA with a bleb that led to the diagnosis of a ruptured BAA only 3 mm in diameter. After bronchial artery embolisation, the haemoptysis ceased. Although rare, a ruptured BAA should be considered as a cause of massive haemoptysis. Because a small BAA may get overlooked, close observation is important in BAG.

Cephalic tetanus as a differential diagnosis of facial nerve palsy.

Cephalic tetanus is defined as a combination of trismus and paralysis of one or more cranial nerves. Since it is a rare cause of facial nerve palsy, it is often overlooked as a differential diagnosis. We present the case of a 75-year-old man admitted to our emergency department with left facial nerve palsy, left ptosis and dysphagia 2 weeks after a head laceration. Soon after admission, he was orally intubated because of massive aspiration. A delayed diagnosis of cephalic tetanus was reached only when he was extubated and trismus and risus sardonicus were identified in addition to facial nerve palsy. The patient was re-intubated and successfully extubated on day 20 postadmission. In orally intubated patients, trismus and risus sardonicus may be overlooked, and although rare, cephalic tetanus should be considered to be a differential diagnosis of facial nerve palsy.

Hypotension induced by the concomitant use of a calcium-channel blocker and clarithromycin.

In the elderly, calcium-channel blockers are the first-line treatment for hypertension, and macrolides are commonly prescribed antibiotics. Here we report a 78-year-old man taking nifedipine, diltiazem and carvedilol who presented with persistent hypotension and bradycardia after clarithromycin was prescribed. He was diagnosed with drug-induced hypotension and treated with fluid resuscitation and vasoactive agents. His symptoms gradually improved. He was transferred out of the intensive care unit 3 days after hospitalisation. Combining calcium-channel blockers and clarithromycin can cause vasodilatory hypotension. The concomitant use of calcium-channel blockers and macrolide antibiotics increases the levels of calcium-channel blockers in the blood as they are metabolised by cytochrome P450 3A4 (CYP3A4), which is inhibited by macrolide antibiotics. Moreover, the addition of another calcium-channel blocker and a ß blocker can lower cardiac output due to bradycardia and worsen hypotension. Therefore, it is important to consider drug interactions when the cause of hypotension is unknown.

Validation of the diagnostic utility of D-dimer measurement in patients with acute aortic syndrome.

OBJECTIVE: The objective of this study was to evaluate the validity of D-dimer measurements for the diagnosis of acute aortic syndrome in patients admitted to hospital with acute chest pain. METHODS: A retrospective observational study design was used. Consecutive patients ( n=887) admitted to a tertiary hospital with acute chest pain (acute aortic syndrome, 123; acute pulmonary embolism, 29; and other disease, 735) from the emergency department between January 2011 and April 2014 were assessed to validate the diagnostic value of D-dimer measurements. RESULTS: The D-dimer level was significantly increased in patients with acute aortic syndrome (median (interquartile range) 4.9 (2.0-17.4) µg/ml) compared with control patients (median (interquartile range) 0.6 (0.3-1.4) µg/ml; p<0.001). At a cut-off point of 0.5 µg/ml, the sensitivity for acute aortic syndrome was 0.97 (95% confidence interval 0.92-0.99) and was similar to that for acute pulmonary embolism (0.97 (0.82-0.99)). The age-adjusted D-dimer cut-off point, defined as age × 0.01 µg/ml in patients ⩾50 years, successfully reduced the number of false-positive diagnoses by 13%, while still retaining a high sensitivity (0.96 (0.91-0.99)). The five false-negative diagnoses of acute aortic syndrome included three patients with intramural haematoma, one patient with a penetrating aortic ulcer and one patient with an impending aortic rupture. A combination of probability assessment and the D-dimer approach reduced the number of false-negatives from five patients to two patients. CONCLUSIONS: This study demonstrated that the D-dimer test can distinguish acute aortic syndrome from other diseases presenting with acute chest pain with high sensitivity and modest specificity. Using the D-dimer approach presents limitations with some subtypes of acute aortic syndrome, such as intramural haematoma.

Timing of craniotomy in a patient with multiple trauma including head injury.

A 7-year-old boy suffered blunt multiple injuries to the head, face, chest, and abdomen in a motor vehicle accident. On admission he had impaired consciousness and dyspnea. Radiographic studies revealed facial fracture and pulmonary contusion. Shortly after admission, he fell into shock due to intraabdominal bleeding. Laparotomy revealed spleen rupture. His vital signs remained unstable and bloody drainage from the abdominal cavity continued after surgery. Computed tomography showed traumatic intracerebral hematoma in the right temporal lobe, enlarging and compressing the brainstem. Abdominal reoperation was performed first to control the bleeding and stabilize the hemodynamics, disclosing renal laceration. Then evacuation of the intracerebral hematoma and decompressive craniectomy was performed. Postoperatively, his hemodynamics were stabilized. Clinical course was uneventful and neurological deficits gradually improved. Three months after the trauma, the patient was discharged on foot. This case emphasizes the importance of hemodynamic stability in decisions of neurosurgical indication and timing in patients with multiple trauma including head injury.