BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure to manage severe hemorrhagic shock from torso injury but can cause severe ischemia of the lower extremities. However, lower extremity ischemia occurring as a complication of REBOA has been rarely reported. We describe the severe lower extremity ischemia caused by REBOA with a 12-Fr sheath in a small-built patient.Case representationThe patient was a 16-year-old male who developed severe hemorrhagic shock due to abdominal blunt trauma. Following REBOA with a 12-Fr sheath on the right femoral artery, an emergency laparotomy and angiography to control the hemorrhage were performed. Twenty-eight hours after admission, suspecting lower extremity ischemia and compartment syndrome, we removed the sheath with a manual maneuver and performed fasciotomy. The limb ischemia was thus partially resolved. However, amputation was necessary because of ischemic necrosis on day 32. Our patient was physically small, and the diameter of his femoral artery on the contralateral site of sheath placement was also small. Therefore, disproportion of the sheath and femoral artery sizes may have caused the ischemic complication.ConclusionOur experience highlights the importance of appropriate size selection for the sheath in line with the target vessel. We also recommend postoperative monitoring of limb perfusion in such cases with the use of near-infrared spectroscopy to facilitate the early detection of ischemia.
BackgroundResuscitative balloon occlusion of the aorta (REBOA) can maintain hemodynamic stability during hemorrhagic shock after a following torso injury, although inappropriate balloon placement may induce brain or visceral organ ischemia. External anatomical landmarks [the suprasternal notch (SSN) and xiphoid process (Xi)] are empirically used to implement REBOA in zone 1. We aimed to confirm if these landmarks were useful for determining a balloon catheter length for safe implementation of REBOA in zone 1 without using fluoroscopy.MethodWe selected 25 successive adult blunt trauma cases requiring contrast-enhanced chest/abdominal computed tomography (CT) treated at our emergency department (in an urban area of Kyoto city, Japan) between October 1, 2016 and January 31, 2017. We retrospectively evaluated anonymized CT images. We used three-dimensional multiplanar reconstructions to measure the length along the aorta’s central axis, from the bilateral common femoral arteries (FA) to the celiac trunk (CeT) (FA–CeT) and to the origin of the left subclavian artery (LSCA) (FA–LSCA). Volume-rendering reconstruction images were used to measure the external distance from common FAs to SSN (FA–SSN) and to Xi (FA–Xi).ResultFA–LSCA was significantly longer than FA–SSN. FA–CeT was significantly shorter than FA–Xi.DiscussionBased on these results, the REBOA balloon catheter should be shorter than FA–SSN, and longer than FA–Xi to avoid placement outside zone 1. The advantages of this method are that it can rapidly and easily predict a safe balloon catheter length, and it reflects each patient’s individual torso height.ConclusionTo safely implement REBOA, the balloon catheter length should be shorter than FA–SSN and longer than FA–Xi. We believe that these anatomical landmarks are good references for safe implementation of REBOA in zone 1 without radiographic guidance.
BackgroundCatecholamine agents are commonly used to support circulation; however, they may cause unexpected hypotension in a special situation. Here we describe the first unexpected case of hypotension in response to catecholamine agents.Case presentationA 29-year-old Japanese man with schizophrenia was transferred to our emergency department. He was in shock and in coma. After fluid resuscitation, we induced catecholamine agents; however, his blood pressure decreased to 59/40 mmHg in response to catecholamine infusion. On the other hand, after we started vasopressin, his blood pressure markedly improved, and he finally became stable. On day 2, he admitted to ingesting a large amount of risperidone, and we diagnosed risperidone overdose. We believe that this unexpected hypotension in response to catecholamine infusion was caused by an α-adrenergic blockade effect of risperidone. Animal experiments proved that the simultaneous administration of adrenaline with an α-adrenergic blockade provoked a fall in blood pressure; this phenomenon is called “adrenaline reversal.” In our case, catecholamine infusion under the α-adrenergic blockade effect of risperidone might have caused a fall in blood pressure in the same mechanism; we call this phenomenon “catecholamine reversal.” In such a situation, because the mechanism of vasopressin is different from that of catecholamine, we recommend vasopressin for maintaining the blood pressure.ConclusionsWe described the first clinical case of “catecholamine reversal” and highlighted that if unexpected hypotension occurs in response to catecholamine infusion, we should suspect the use of α-adrenergic antagonists. In such situations, we should consider the administration of vasopressin instead.
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