Transesophageal echocardiography identification of aortic dissection during cardiac arrest and cessation of ECMO initiation

Cardiac arrest is a challenging clinical presentation that emergency medicine providers often encounter. Aortic dissection is an uncommon etiology in all-comers presenting in cardiac arrest. The use of bedside point of care echocardiography to aid in resuscitative efforts is expanding, particularly with the increasing use of transesophageal echocardiography (TEE) by emergency medicine providers. Additionally, emergency department initiation of extracorporeal membrane oxygenation (ECMO) is a relatively newer development in emergency department practice. We report the case of a 64-year old male presenting to the emergency department in cardiac arrest with TEE identification of aortic dissection as the etiology resulting in discontinuation of ECMO initiation attempts.     

Tension empyema as a reversible cause for cardiac arrest

Empyema is a well recognised complication of pneumonia.1 We report a case of pulseless electrical activity (PEA) treated in the emergency department (ED) with intercostal tube drainage based on clinical findings, where a tension empyema was found to be the cause. To our knowledge, this is the first report of actual cardiac arrest from this cause.     

Headache: an unusual presentation of aortic dissection.

The most common presenting symptom of aortic dissection is chest pain - headache as the initial manifestation is rare. We report a patient with a history of hypertension who presented with severe bifrontal headache, and was found to have an acute aortic dissection in the absence of carotid artery dissection. A discussion of the atypical presentation and possible pathophysiology follows.     

Chronic aortic dissection as a cause of fever of unknown origin

Chronic aortic dissection presenting as a prolonged febrile syndrome is an uncommon condition. We believe that only 22 cases have been previously reported. We present a case of a patient with an aortic dissection whose diagnosis was delayed because persistent fever, malaise, and night sweats dominated his clinical picture. These complaints may be accompanied by an increased erythrocyte sedimentation rate, leukocytosis, thrombocytosis, and anemia of chronic disease. Knowledge of this atypical presentation, a high degree of suspicion, and investigation using an adequate imaging method will help to avoid missing this potentially lethal entity.     

Acute aortic dissection: population-based incidence compared with degenerative aortic aneurysm rupture

OBJECTIVES: To ascertain whether acute aortic dissection (AAD) remains the most common aortic catastrophe, as generally believed, and to detect any improvement in outcomes compared with previously reported population-based data. PATIENTS AND METHODS: We determined the incidence, operative intervention rate, and long-term survival rate of Olmsted County, Minnesota, residents with a clinical diagnosis of AAD initially made between 1980 and 1994. The incidence of degenerative thoracic aortic aneurysm (TAA) rupture was also delineated. We compared these results with other population-based studies of AAD, degenerative TAA, and abdominal aortic aneurysm (AAA) rupture. RESULTS: During a 15-year period, we identified 177 patients with thoracic aortic disease. We focused on 39 patients with AAD (22% of the entire cohort) and 28 with TAA rupture (16%). The annual age- and sex-adjusted incidences were 3.5 per 100,000 persons (95% confidence interval, 2.4-4.6) for AAD and 3.5 per 100,000 persons (95% confidence interval, 2.2-4.9) for TAA rupture. Thirty-three dissections (85%) involved the ascending aorta, whereas 6 (15%) involved only the descending aorta. Nineteen patients (49%) underwent 22 operations for AAD, with a 30-day case fatality rate of 9%. Among all 39 patients with AAD, median survival was only 3 days. Overall 5-year survival for those with AAD improved to 32% compared with only 5% in this community between 1951 and 1980. CONCLUSIONS: In other studies, the annual incidences of TAA rupture and AAA rupture are estimated at approximately 3 and 9 per 100,000 persons, respectively. This study indicates that AAD and ruptured degenerative TAA occur with similar frequency but less commonly than ruptured AAA. Although timely recognition and management remain problematic, these new data suggest that recent diagnostic and operative advances are improving long-term survival in AAD.     

Tension urinothorax as a reversible cause of cardiac arrest: a case report

<正>Urinothorax, is the accumulation of urine in the pleural space, and is a rare and unusual condition.[1]Several etiologies are responsible for this, with trauma being the most common,[2] along with, surgical renal procedures(percutaneousnephrolithotomy,PCNL),retroperitoneal inflammation, urinary obstruction and malignancies.[3,4] Massive collections of a urinothorax or a hydrothorax can lead to tension, mediastinal shifts andcardiacarrests. Wedescribeacaseoftension urinothorax that led t...     

Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest.

OBJECTIVE: Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest is poorly evaluated. We analyse disease-specific and emergency care data in order to improve the recognition of subarachnoid haemorrhage as a cause of cardiac arrest. DESIGN: We searched a registry of cardiac arrest patients admitted after primarily successful resuscitation to an emergency department retrospectively and analysed the records of subarachnoid haemorrhage patients for predictive features. RESULTS: Over 8.5 years, spontaneous subarachnoidal haemorrhage was identified as the immediate cause in 27 (4%) of 765 out-of-hospital cardiac arrests. Of these 27 patients, 24 (89%) presented with at least three or more of the following common features: female gender (63%), age under 40 years (44%), lack of co-morbidity (70%), headache prior to cardiac arrest (39%), asystole or pulseless electric activity as the initial cardiac rhythm (93%), and no recovery of brain stem reflexes (89%). In six patients (22%), an intraventricular drain was placed, one of them (4%) survived to hospital discharge with a favourable outcome. CONCLUSIONS: Subarachnoid haemorrhage complicated by cardiac arrest is almost always fatal even when a spontaneous circulation can be restored initially. This is due to the severity of brain damage. Subarachnoid haemorrhage may present in young patients without any previous medical history with cardiac arrest masking the diagnosis initially.     

An unusual presentation of ascending aortic arch dissection

The following case report is that of a young man who collapsed on a golf course during a heat advisory. The prehospital presentation suggested that the patient was suffering from heat exhaustion. In the Emergency Department, the patient's condition continued to deteriorate despite aggressive rehydration and cooling efforts. Aggressive evaluation and treatment of the patient led to the diagnosis of an acute painless dissection of the ascending aorta.     

Prediction of outcome after cardiac arrest

Neurologic outcome of hypoxic ischemic coma after cardiac arrest was studied in 32 patients. Observations were made and samples collected 24 and 48 h after the ischemic insult. The Glasgow-Pittsburgh coma score was assessed for its prognostic value. Other variables studied were the EEG and adenylate kinase, lactate and glutathione in the cerebrospinal fluid (CSF). Outcome was termed good if the patients resumed an independent life within a 6-month follow-up period. The closest correlations between prediction and good outcome occurred with the Glasgow-Pittsburgh coma score (94%) and the EEG (77%) at the 48-h examination, a modified coma score (96%) at 48 h, and CSF lactate (78%) at 24 h. Some simple neurologic signs (e.g., no withdrawal response to pain) at stated points in time was 100% associated with a bad outcome, although their absence was not associated necessarily with a good prognosis.     

Acute concomitant pulmonary artery and aortic dissection with rupture

Pulmonary artery (PA) dissection is uncommon and may lead to rupture and sudden death if encountered. A 63-year-old man presented to our emergency room with episodic left chest pain radiating to the back followed by shortness of breath. A 64-row multidetector computed tomography (MDCT) revealed ruptured dissection of the PA and the aorta with hemopericardium, hemomediastinum, and prominent extravasated blood along the central bronchovascular bundles of both lungs. The patient experienced cardiogenic shock immediately following CT study and died after resuscitation. Concomitant PA and aortic dissection with rupture is extremely rare with the pathogenesis remaining investigated. MDCT proves to be a powerful tool in its diagnosis for a timely surgical repair if the patient could survive to have the operation.     

Spontaneous retropharyngeal hematoma: an unusual presentation of thoracic aortic dissection

A 78-year-old woman presented to the Emergency Department with spontaneous ecchymosis and swelling of the neck. Ecchymosis was also evident on the posterior pharyngeal wall. A lateral soft tissue radiograph demonstrated a retropharyngeal hematoma, which was confirmed by computed tomography (CT). At this time there was no evidence of airway obstruction and she was admitted for observation. One week after admission she became acutely short of breath, and a chest radiograph at this time showed a large pleural effusion. Pleural drainage confirmed this to be a hemothorax. Subsequent CT revealed a thoracic aortic dissection with blood communicating into both the retropharyngeal space and the pleural cavity. The case highlights both an unusual presentation of thoracic aortic dissection, and also the potential for occult hemorrhage in cases of spontaneous retropharyngeal hematoma.