Thanks for your concern and opinion about our article. To determine the influence of underlying diseases on the BNP values, this survey was performed the non-CHF patients only. Therefore, the patients who had myocardical dysfunction caused by sepsis was excluded in this survey. In discussion, it was described that BNP values were increased in the patients of hypertension more than non-hypertension patients due to increasement of lt-ventricle mass index. Therefore we agree with your opinion. Underlying diseases (COPD, HTN, et al) were diagnosed at the time of discharge, and so we hardly miss. This study was conducted on dyspnea patients not healthy people. We think the target of study was different from your opinion. Nevertheless, it will be better if further study is done with large population of patients.

A 62-year-old gentleman presented with a 10-day history of right sided pleuritic chest pain and shortness of breath. Chest X-ray (CXR) on admission (left) confirmed a primary spontaneous pneumothorax of the right lung. This was treated with simple needle aspiration. CXR immediately after the procedure (middle) showed re-expansion of the right lung with unilateral pulmonary oedema. Subsequent CXR (right) demonstrated complete resolution of both the pneumothorax and re-expansion pulmonary oedema (REPO).

REPO is an extremely uncommon but recognised complication of re-expansion of the lung following evacuation of either air or fluid from the pleural space. REPO has an overall incidence of 1% and its occurrence after simple needle aspiration of pneumothorax is exceptionally rare. Despite treatment which involves resuscitation with intravenous fluid and oxygen therapy, REPO is potentially fatal with mortality as high as 20%.

Dear editor

I have read with interest the replies to Lee and Porter’s article on suspension trauma. As a mountain rescue doctor I have been involved in the care of an individual with suspected suspension trauma. The patient fell 10 metres vertically onto a 40 degree scree slope, with feet facing down the slope and reluctant to place the pelvis on the ground as it caused an increase in pain in both legs. Paramedics immobilised in a vacuum mattress with legs outstretched – still facing downhill, (Morphine Sulphate being used to relieve pain). The team attended to assist in extraction, the patient had been immobile in excess of two hours.

The patient was not suspended vertically but was immobilised at a significant angle for a period of time. This prevented leg movement and recirculation of the pooled venous blood – alerting us to possible suspension trauma and hence raising the casualty’s feet. The side effects of morphine, (hypotension, nausea, dizziness, and bradycardia), are similar to the effects of suspension trauma, except for the narrow pulse pressure and dilated pupils present in this patient. It could be argued that a significant sympathetic drive would occur from the pain and fear of sliding, which prevented further onset. The absence of a tachycardia does not support this. The non specific bilateral leg pain may indicate suspension trauma associated paraesthesia, rather than mechanical injury. No hypovolaemia, back, pelvic or lower limb injury were confirmed in hospital and the patient denied further pain.

It must be noted that if a casualty becomes unconscious whilst in suspension their airway will be become obstructed, either by neck flexion or hyperextension, masking any signs of suspension trauma. In training risk of suspension trauma is grouped as follows:

1. Full body harness with posterior attachment point - low risk.

2. Sit harness with anterior attachment – low risk. Casualty will hang almost horizontal, but additional weight can alter their centre of gravity changing the angle of suspension1. If still conscious they will attempt to recommence climbing or be lowered by the second climber to a better position.

3. Full body harness with chest and waist attachment points – high risk. Used in caving and industrial rope access as it allows rapid ascent and descent of the rope. The unconscious casualty will remain in a vertical position; reducing the time to brain hypoxia secondary to reduced cerebral perfusion pressure from venous pooling and concomitant reduction in cardiac output. Consequently rope access technicians must be able to rescue and descend to safety in less than ten minutes2.

4. Third party induced. This group are placed in suspension by other individuals and are at high risk. This includes rescue personnel immobilising casualties.

This case demonstrates that suspension trauma is not hypothetical and may present with varying symptoms and under varying conditions. It has a small incidence following changes in harness design and education of those at risk, but must be considered during rescue and in hospital if a history of prolonged suspension at any angle is mentioned.

Regards

Dr Patrick Morgan

Avon and Somerset Cliff Rescue Team

References

1. Hillebrandt, D. Suspension Trauma in UK Climbers? Emerg Med J, e- letter. 2007, 12 June.

2. Guidance on rescue during work at height. Technical Guidance Note 5. The Work at Height Safety Association. www.wahsa.org.uk. 2006.

Reply to confusion of Rupture and Dissection

We thank Dr Reid for his comments regarding the above paper. The case described related to a seventy-three year old gentleman who was found sitting at the wheel of his car in a collapsed state with a left-sided hemiplegia. The patient was found to regain full power of his left side when laid flat. This postural alteration in his neurological symptoms was the point of interest which we were seeking to elucidate, as this patient was subsequently found at post mortem to have a ruptured abdominal aortic aneurysm with no thoracic involvement. These neurological symptoms were attributed to quiescent carotid artery disease (which was subsequently revealed at post mortem). This carotid artery disease manifested with a left sided hemiplegia in the context of severe postural hypotension which had resulted from rupture of his abdominal aortic aneurysm. Dissection of Thoracic Aortic Aneurysm frequently manifests in neurological signs not dissimilar to the initial presentation of this patient. It was for this reason that papers relating to DTAA were referenced. We hope this clarifies the confusion expressed by Dr Reid.