A case of pulmonary visceral subpleural hematoma treated by hematoma evacuation during care of post-cardiopulmonary resuscitation.

BACKGROUND: The occurrence of pulmonary visceral subpleural hematoma during care of post-cardiopulmonary resuscitation including chest compressions and anticoagulant and antiplatelet therapies is extremely rare. Also, there are few reports of treatment of visceral subpleural hematoma, most of which are treated by lung resection. Here we describe a rare case that pulmonary visceral subpleural hematoma arose during post-cardiopulmonary resuscitation care and was treated by hematoma evacuation. CASE PRESENTATION: A 58-year-old male with no smoking history and, past medical histories of rheumatoid arthritis, chronic atrial fibrillation, hypertension, diabetes, and dyslipidemia developed ventricular fibrillation due to myocardial infarction and fainted. He received bystander cardiopulmonary resuscitation and defibrillation by the ambulance crew and had return of spontaneous circulation. After transfer to our hospital, the patient underwent percutaneous catheter intervention and stenting with a diagnosis of myocardial infarction, followed by anticoagulant and antiplatelet therapies. On the 8th hospital day, chest radiography suggested right lower lobe pneumonia, and subsequent chest computed tomography revealed pulmonary hematoma in the visceral subpleural area from S6 to S10. Since no improvement was observed in hypoxemia, treatment was considered necessary. First, an attempt at computed tomography-guided drainage of hematoma was made, but insertion of the Pig-tail catheter was difficult due to hardness of the hematoma. Next, evacuation of hematoma was performed on the 13th hospital day. The hematoma was located in the visceral subpleural area and was removed by incising the pleura. TachoSil Tissue Sealing sheet and Polyglycoal acid sheet were applied to the sites of air leakage and oozing after hematoma evacuation. No re-bleeding or air leakage was observed after the treatment, and the patient was discharged on the 26th hospital day after an uneventful course. CONCLUSIONS: Pulmonary visceral subpleural hematoma may occur during post-cardiopulmonary resuscitation care, including chest compressions and anticoagulant and antiplatelet therapies. In our case, CT-guided puncture and drainage was difficult and surgical treatment by incision of the visceral pleura and hematoma evacuation alone was done successfully.

Effectiveness of a doctor dispatch system activated by an advanced automatic collision notification from a single-vehicle accident: A case report.

A 79-year-old woman collided with a cliff in a passenger automobile. The fire department acknowledged an automated collision notification from the D-Call Net (DCN) at 1 min after the accident and called for doctors by helicopter ("Doctor-Heli" [DH] in Japan) 9 min after the injury. The DH reached the victim 28 min after the injury, and examinations revealed pain in the right side of her chest, tachypnea, and a weak radial artery pulse (indicating shock). The DH arrived at the hospital 49 min after the injury. A thoracic drainage was performed for right-sided tension pneumothorax. She recovered from the shock, but was diagnosed with flail chest and placed on a respirator. She was extubated on postoperative day 6 and transferred to a rehabilitation hospital on postoperative day 57. Due to the DCN, the patient received treatment 15 min earlier than the time taken by the conventional system. Emergency response task forces must develop strategies for connecting DCN warnings to a rapid medical response.

A case of severe hemorrhagic shock caused by traumatic avulsion of uterine fibroid.

Case presentation: A 40-year-old woman was injured in a motor vehicle accident. Physician-staffed helicopter emergency medical service (HEMS) was dispatched, and after the HEMS physician performed thoracostomy and tracheal intubation to relieve the tension pneumothorax and hemorrhagic shock, her carotid artery became unpalpable. The physician then decided to perform prehospital resuscitative thoracotomy. Immediately after arriving at the hospital, an emergency laparotomy was performed. Intraoperative findings showed that a huge uterine fibroid had been avulsed from the uterine wall, and we performed temporary hemostasis by extraction of the avulsed tumor and application of packing to the pelvic cavity. She was transferred to a rehabilitation hospital 42 days after the operation. Conclusion: The injury mechanism in this case was considered a "submarine effect." This was an extremely rare case in which the acute care surgeon and a gynecologist collaboratively employed a damage control strategy to deal with impending cardiac arrest.

Emergent surgery for cardiac herniation coexisting with complex blunt cardiac injury: A case report.

A 38-year-old man was pressed on his trunk by a heavy object weighing about 100 kg. The patient was in shock status on arrival to the hospital. Circular collapse progressed rapidly during contrast computed tomography (CT) scanning. CT images revealed exacerbation of the right lateral deviation of the heart that was earlier seen on X-ray imaging. Considering cardiac herniation based on CT findings, we immediately performed resuscitative thoracotomy and clamshell thoracotomy at the emergency department. Intraoperative findings showed a pericardial defect, and the heart had deviated to the right thoracic cavity. Immediate repositioning revealed a marked improvement in circulation. Full-thickness cardiac injury was observed in the anterior wall of the left ventricle; no active bleeding was observed. We performed temporary thoracic wall closure after cardiorraphy for damage control. After admission to the intensive care unit, he presented with respiratory failure associated with pulmonary contusion. Therefore, veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used from the 2nd to the 5th hospital day. After confirming no intra-thoracic events on the 6th hospital day, chest wall closure was performed. The patient subsequently developed heart failure and mitral regurgitation associated with papillary muscle rupture. On the 62nd hospital day, he underwent mitral annuloplasty at the cardiovascular surgery division; After rehabilitation till 152nd hospital day, he was discharged without any neurological abnormality. This was an extremely rare case with concomitant full-thickness myocardial injury, intracardiac injury, and cardiac herniation. Rapid resuscitative thoracotomy and damage control including V-V ECMO yielded good results. Retrospectively, cardiac herniation should have been suspected earlier basis this observation. Our report highlights that cardiac herniation should be considered in case of cardiac shadow aberrations in cases of blunt chest trauma, familiarity with condition and its characteristic imaging findings are critical for the doctor overseeing initial trauma treatment.