Shock resuscitation with acupuncture: a case report

▸ On 25 August 2004, Typhoon Aere battered northern Taiwan. Torrential rains that soaked the island throughout the night washed away roads in mountainous Hsin-Chu county. A 77 year old aboriginal female became drowsy due to septic shock in an isolated village. The roads were seriously destroyed by typhoon. Helicopter was the only means for delivering critical medical care and support. Poor weather conditions delayed the arrival of the medical and support team. Without emergency medical equipment, the patient was passing away while waiting for the arrival of the helicopter. With persistent emergency acupuncture stimulation administered for 80 minutes, the patient was kept vital sign until successful transferal to hospital care. She recovered without any complications of shock and was discharged six days later.

Shock resuscitation is an emergence and critical procedure. Many advanced viewpoints of shock resuscitation and critical medical care were proposed, but none of acupuncture. How emergency acupuncture stimulation benefits shock resuscitation remains unclear. Although the findings need to be verified with a larger sample, the initial results did show the beneficial effects of emergency acupuncture stimulation for shock resuscitation. The definitive benefits need to be further determined.

Bolus thrombolytic infusion during prolonged refractory cardiac arrest of undiagnosed cause

▸ Despite advances in resuscitation research, cardiac arrest still carries a poor prognosis. More than 70% of cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is an effective therapy for both AMI and PE; it is not routinely recommended during cardiopulmonary resuscitation (CPR) due to fear of life threatening bleeding complications. We present a case of successful use of bolus thrombolytics during CPR in a patient with undifferentiated cardiac arrest (undiagnosed cause) after prolonged conventional resuscitation without response to conventional resuscitative efforts. While most of the clinical evidence suggests beneficial effect of thrombolysis in cardiac arrest secondary to AMI or PE, our case documents a beneficial outcome in undifferentiated cardiac arrest with prolonged unsuccessful conventional resuscitation. The effectiveness of thrombolytics during CPR can be explained its local action at the site of coronary or pulmonary vessel thrombosis leading to rapid correction of underlying pathology, and a neuroprotective effect secondary to its action on microcirculatory reperfusion. Current clinical data, although encouraging, is insufficient to recommend routine use of bolus thrombolytic during CPR in all patients. There is a need for randomised prospective studies to identify patient who would benefit from such intervention.

Lower limb amputation with CPR in progress: recovery following prolonged cardiac arrest

▸ Summary Intravenous drug users (IVDUs) often present to emergency services with the medical complications of drug use. We report a case in which an acutely ischaemic lower limb of one such patient was thought to be the cause of cardiac arrest occurring during treatment in the Emergency Department (ED). Amputation of the limb was performed with cardiopulmonary resuscitation (CPR) in progress, spontaneous cardiac output was restored and the patient made an excellent neurological recovery despite a total arrest time of 85 minutes. Possible causes of cardiac arrest, in relation to the release of potassium and metabolic toxins are discussed, as well as the decision-making processes of the involved clinicians and other possible management strategies.

Contact burns from hair straighteners: a new hazard in the home

▸ This report highlights a previously unreported household hazard for children, hair straighteners. Thermal injury is a common reason for presentation at the emergency department. The majority of these injuries are superficial in nature with few requiring surgery. Contact burns from domestic irons are well documented. We have become aware of this new hazard in the home, which has resulted in several presentations to our department with deep partial thickness or full thickness burns. Two cases required formal excision and split-skin grafting. Non-accidental injury was considered and thought to be unlikely. Hair straighteners are made of either bare metal or ceramic, and are designed to heat up to temperatures of 180–220°C. The resting position often leaves the hot plates exposed, compromising safety. The upper temperature limit for an accidental contact of one second with an uncoated metal surface is 70 degrees centigrade. This rises to 86 degrees for a ceramic surface. Temperatures greater than these or contact durations of greater than one second cause burns. Young children are naturally curious and have delicate skin making them particularly at risk of contact burns, parents must recognise this and be rigorous in applying general safety rules when using hazardous appliances.

Successful resuscitation of hypermagnesaemic asystolic cardiac arrest with the use of early transvenous cardiac pacemaker: a case report

▸ A 63 year old female presented to the emergency department (ED) with one week of progressive dyspnea, constipation and generalised weakness. She was 10 days status post lumbar spinal fusion surgery and had a history of chronic renal insufficiency. The patient had been using milk of magnesia and magnesium citrate in unknown amounts to alleviate her constipation over this time frame. During her ED stay she became progressively hypotensive and bradycardic and despite aggressive resuscitative measures she suffered an asystolic arrest one hour into her ED course. She was resuscitated with conventional therapy, but her hemodynamic profile did not improve significantly until transvenous cardiac pacing was employed. Her magnesium level was 10.4 mmol/L.

Treatment of magnesium overload has focused upon hemodialysis, forced diuresis, and the use of intravenous calcium salts. Case reports have previously documented survival of moderately to severely ill patients when these modalities have been used. Likewise, failure of resuscitation despite use of these methods has been previously noted. To the authors’ knowledge this is the first reported case clearly demonstrating the efficacy of transvenous cardiac pacing to successfully resuscitate a patient upon whom multiple vasopressors, fluids and calcium previously had no clear effect.

Volar dislocation of the index carpometacarpal joint in association with a Bennett’s fracture of the thumb: a rare injury pattern

▸ We describe a case of volar dislocation of the second carpometacarpal joint in association with a Bennett’s fracture of the thumb following a motorcycle accident. Volar dislocation of the carpometacarpal joint is an exceedingly rare but easily missed injury with only a few reported cases in the literature. This report highlights the importance of a true lateral x-ray and close scrutiny of the film to detect this injury. Closed reduction supplemented with kirschner wire fixation restored normal wrist anatomical relations and achieved an excellent clinical result.

SEEING THE INVISIBLE: PAINLESS AORTIC DISSECTION IN THE EMERGENCY SETTING

▸ Acute dissection of the aorta is among the most dramatic cardiovascular emergencies. However, a timely diagnosis can be elusive in the event of an atypical presentation.

In this report, we present two patients with painless aortic dissection who were misdiagnosed during their initial evaluation in the emergency department.

A previously healthy 25 year old man was admitted to the emergency department (ED) with shortness of breath, pink sputum, cough, and fever. The patient was admitted to the coronary care unit with the diagnosis of “myocarditis associated with pneumonia”. Another patient 86 year old man was admitted to the ED with complaints of increasing fatigue for 10 days, and dyspnea and palpitations over the previous three to four days. The patient was admitted to the cardiology ward with the diagnosis “pericarditis”. However, the patient insisted to be discharged from the hospital without further evaluation. After 10 days, the patient presented to the ED again with complaints of paresthesia and weakness in the right leg.

In conclusion, a high index of suspicion is of vital importance in establishing a diagnosis of this catastrophic emergency which is associated with serious morbidity and mortality.