Left internal mammary artery injury and subsequent hypovolemic shock due to a hemothorax after subxiphoid pericardiocentesis in a postoperative cardiac surgery patient.
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ABSTRACT:
SUBMITTER: Oudeman MAP
PROVIDER: S-EPMC8077242 | biostudies-literature | 2021 Apr
REPOSITORIES: biostudies-literature
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Left internal mammary artery injury and subsequent hypovolemic shock due to a hemothorax after subxiphoid pericardiocentesis in a postoperative cardiac surgery patient.
Oudeman Maurice A P MAP Planken R Nils RN Beijk Marcel A M MAM
Clinical case reports 20210307 4
Multimodality imaging is recommended in patients in shock after seemingly uneventful pericardiocentesis. The aim of this study was to heighten awareness that LIMA injury can lead to a life-threatening hemothorax in postoperative cardiac surgery patients. ...[more]
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Project description:IntroductionVolume depletion is a common problem in pediatrics. Interns need to be able to recognize critical illness such as hypovolemic shock, obtain access, and manage complications. This simulation case involves a child with hypovolemic shock who requires intraosseous (IO) needle placement. While designed for subinterns in pediatrics, it is relevant for clerkship students and interns in family medicine and emergency medicine.MethodsIn this case, a 3-year-old child presents with vomiting, diarrhea, and lethargy, and is in hypovolemic shock. As IV access cannot be obtained, he requires IO access. Laboratory results reveal hypoglycemia, hypernatremia, and acute kidney injury. Required equipment includes an IV arm task trainer and a child mannequin with IO capacity (or a child mannequin plus a separate IO task trainer). Learning objectives include recognizing and managing hypovolemic shock, hypoglycemia, and electrolyte disturbances; obtaining IO access; and communicating with a distraught parent. Critical actions include attempting IO access, requesting labs, and administering fluids. Students complete a selfassessment survey following the case.ResultsA pilot study was conducted in 2017 with all subinterns (N = 16) on the pediatric service. Students' perceived competence in assessment and management of volume depletion and procedural skills such as IO placement were high following the session, and students rated the case as a highly beneficial learning experience.DiscussionThis clinical simulation case allows students to demonstrate clinical reasoning skills, procedural skills, and management skills regarding hypovolemic shock. It may be used as part of a curriculum for fourth-year students entering pediatric residency.
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Project description:Births involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn's access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic-ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal-placental circulation allowed by an intact cord.
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Project description:BackgroundPericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound-guided apical approach in patients with chronic pericardial effusion.MethodsAmong 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis.ResultsA subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group.ConclusionThe subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.
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Project description: Not available
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Project description:BackgroundMassive hemothorax secondary to thoracic spinal fractures is rare, and its clinical characteristics, treatment, and prognosis are unknown. We present two cases of thoracic spinal fracture-induced massive hemothorax and a systematic review of previously reported cases.MethodsThis study included patients with traumatic hemothorax from thoracic spinal fractures at a Japanese tertiary care hospital. A systematic review of published cases was undertaken through searches in PubMed, EMBASE, and ICHUSHI from inception to October 13, 2019.ResultsCase 1: An 81-year-old man developed hemodynamic instability from a right hemothorax with multiple rib fractures following a pedestrian-vehicle accident; > 1500 mL blood was evacuated through the intercostal drain. Thoracotomy showed hemorrhage from a T8-burst fracture, and gauze packing was used for hemostasis. Case 2: A 64-year-old man with right hemothorax and hypotension after a fall from height had hemorrhage from a T7-burst fracture, detected on thoracotomy, which was sealed with bone wax. Hypotension recurred during transfer; re-thoracotomy showed bleeding from a T7 fracture, which was packed with bone wax and gauze for hemostasis. The systematic review identified 10 similar cases and analyzed 12 cases, including the abovementioned cases. Inferior part of thoracic spines was prone to injury and induced right-sided hemothorax. Most patients developed hemodynamic instability, and some sustained intra-transfer hemorrhage; direct compression (gauze packing, bone wax, and hemostatic agents) was the commonest hemostatic procedure. The mortality rate was 33.3%.ConclusionsHemothorax due to thoracic spinal fracture can be fatal. Thoracotomy with direct compression is necessary in hemodynamically unstable patients.
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Project description: Not available
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