Mark Walsh

The Use of Therapeutic Hypothermia After Cardiac Arrest in a Pregnant Patient

Therapeutic hypothermia is an effective intervention for the postresuscitative care of patients who have sustained a cardiac arrest. There has been only 1 documented case of successful resuscitation of a pregnant patient and fetus with therapeutic hypothermia, with an abbreviated developmental follow-up of the child. A 33-year-old woman in her 20th week of pregnancy presented to our emergency department after experiencing a cardiac arrest. After successful resuscitation and a discussion with a multidisciplinary team about expected outcomes, the mother and fetus were successfully treated with therapeutic hypothermia, and a healthy baby was delivered 19 weeks later. The mothers cardiac and neurologic function was normal 36 months after the arrest, and the child has reached all growth and neurodevelopmental milestones. We present a case demonstrating excellent immediate and long-term maternal-fetal neurologic, cardiac, and developmental outcomes after the use of therapeutic hypothermia after cardiac arrest in a pregnant patient.

CRASH-2 Study of Tranexamic Acid to Treat Bleeding in Trauma Patients: A Controversy Fueled by Science and Social Media.

This paper reviews the application of tranexamic acid, an antifibrinolytic, to trauma. CRASH-2, a large randomized controlled trial, was the first to show a reduction in mortality and recommend tranexamic acid use in bleeding trauma patients. However, this paper was not without controversy. Its patient recruitment, methodology, and conductance in moderate-to-low income countries cast doubt on its ability to be applied to trauma protocols in countries with mature trauma networks. In addition to traditional vetting in scientific, peer-reviewed journals, CRASH-2 came about at a time when advances in communication technology allowed debate and influence to be leveraged in new forms, specifically through the use of multimedia campaigns, social media, and Internet blogs. This paper presents a comprehensive view of tranexamic acid utilization in trauma from peer-reviewed evidence to novel multimedia influences.

Tranexamic Acid for Trauma Resuscitation in the United States of America

&NA; The utilization of tranexamic acid (TXA) for the management of bleeding trauma patients has been a subject of much debate on both sides of the Atlantic and in Australia. As a result of the large randomized controlled study called the Clinical Randomization of an Antifibrinolytic in Severe Hemorrhage (CRASH‐2), there was an initial enthusiasm for the use of TXA to treat bleeding patients. However, the adoption of TXA in the United States was delayed by concerns of “knowledge and evidence gaps” of the CRASH‐2 study and because of a lack of mechanistic rationale that would explain the survival benefit noted in the study. Subsequent nonrandomized controlled trials questioned the liberal use of TXA in trauma patients. This narrative review explores the historical as well as clinical and theoretical grounds for the more measured use of TXA in the United States and proposes a clinical and point‐of‐care guided utilization of TXA, blood components, and adjunctive hemostatic agents in bleeding trauma patients.

An accompanying genetic severe deficiency of tissue factor protects mice with a protein C deficiency from lethal endotoxemia

Mice with a severe genetic deficiency of protein C (PC), PC(-/-)PC(tg4), display enhanced susceptibility to lethal effects of gram-negative endotoxemia induced by lipopolysaccharide (LPS), whereas mice severely deficient in tissue factor (TF), TF(-/-)hTF(tg), are protected from LPS-mediated lethality. In this study, we show that a simultaneous severe deficiency of TF protected low-PC mice from LPS-induced death, resulting in a survival profile similar to that experienced by wild-type (WT) mice. Plasma and whole blood coagulation assays, the latter measured by thromboelastography, demonstrated development of coagulopathies in LPS-treated mice, which were more severe in the case of the doubly deficient TF(-/-)hTF(tg)/PC(-/-)PC(tg4) mice, mainly reflecting earlier signs of disseminated intravascular coagulation in this latter cohort. Markers of inflammation were also elevated in response to LPS in both groups of mice at times just preceding death. We conclude that whereas coagulopathies are more exacerbated in LPS-treated TF(-/-)hTF(tg)/PC(-/-)PC(tg4) mice, the lowering of TF levels in mice with an accompanying severe PC deficiency confers protection against death compared with mice with a single severe PC deficiency. This suggests that proteases generated as a result of factor VIIa/TF-mediated thrombin generation play a mechanistic role in the enhanced lethality seen under very low PC conditions in an endotoxemia model in mice.

An unruptured, thrombosed 10 cm right coronary artery aneurysm mimicking a pericardial cyst

Giant coronary artery aneurysms are a rare and potentially life-threatening condition. A 47 year old male presented with a progressive 6 month history of dyspnea and acute right sided chest pain. During the patients work-up, a 10 cm × 10 cm right coronary artery aneurysm was discovered on CT scan and confirmed by cardiac catheterization. The patient was emergently taken to the operating room for aneurysmal resection with placement of a greater saphenous vein bypass graft. There were no post-operative complications and the etiology of this patient’s aneurysm was determined to be a congenital ectatic dilation of his right coronary artery. The patient is doing well at 2 years of clinical follow-up.

Therapeutic hypothermia after cardiac arrest.

Materials and Methods Sixty unconscious cardiac arrest patients with return of spontaneous circulation (ROSC) were treated with induced hypothermia in three Swedish hospitals during 18 months. Treatment was induced within two hours post arrest using cold saline (+4°C) (1), after which a water filled wrapping system (ThermoWrap®, MTRE) maintained target temperature at 33±1oC for 24h and controlled re-warming at 0.5 oC/h. The neurological outcome was evaluated at hospital discharge using the CPC-scale (2), where CPC 1-2 represents good outcome (mild or no impairment) and CPC 3-5 represents bad outcome (severe neurological impairment or death).

Proper handling of bullet evidence in trauma patients

Gunshot-related trauma varies in frequency around the world; however, every trauma center should be prepared for and capable of dealing with patients who have sustained gunshot injuries. While the appropriate medical and surgical treatment of gunshot injuries is the goal of the trauma center, many gunshot cases involve situations that have various criminal and/or other forensic concerns. As such, healthcare providers in trauma centers need to be aware of important evidence issues related to gunshot injuries. This paper provides basic information and guidelines for healthcare providers regarding the appropriate identification, documentation, collection, and preservation of forensic evidence in gunshot injury cases.

An unusual cause of dysphagia: Pericardial effusion after implantable cardioverter-defibrillator placement

BACKGROUNDnDysphagia is a known complication of pericardial effusions. Most cases of pericardial effusions are idiopathic, infectious, and neoplastic, but can also occur after cardiac procedures.nnnOBJECTIVEnTo report the case of a patient who developed dysphagia from a sub-acute pericardial effusion caused by the placement of an implantable cardioverter-defibrillator (ICD).nnnCASE REPORTnA 62-year-old woman presented to the Emergency Department (ED) with a 2-day history of dysphagia. Imaging revealed a large pericardial effusion compressing the esophagus from the mid-thoracic level to the gastroesophageal junction. Ten days prior, a dual-chamber ICD with small-diameter active fixation leads was placed in the patient. There had been no apparent complications from the procedure, however, over this 10-day period she developed a sub-acute pericardial effusion from an incidental perforation during ICD lead placement that led to the extrinsic compression of the esophagus and her presenting symptom of dysphagia. The patient underwent pericardiocentesis for the pericardial effusion and she was discharged in stable condition.nnnCONCLUSIONnThis case report highlights the importance of recognizing a non-cardiac complaint such as dysphagia as the primary symptom of a critical cardiac condition. With an increase in cardiac procedures anticipated, clinicians should consider the possibility of a pericardial effusion as a cause of dysphagia, especially for those patients with recent cardiac procedures.