Palpable Peripheral Pulses Research Articles

Snakebite in Switzerland - a potentially life-threatening event?

A 39-year-old healthy patient accidentally stepped barefoot on an adder and was then bitten into the foot. After initially only local complaints, severe systemic symptoms developed within 10-15 minutes with swelling of the lips and soft palate, recurrent vomiting, bradycardia, weakly palpable peripheral pulse, hypotension, dyspnea and intermittent somnolence. The potentially life-threatening consequences of this severe poisoning could be avoided by using adequate emergency measures and immediate intravenous administration of antivenin.

Bedside ultrasonography in diagnosing bilateral femoral arterial occlusion in an elderly patient with acute limb ischemia

Non-traumatic acute limb ischemia is a critical vascular emergency that can lead to limb loss or life-threatening complications1. It is predominantly caused by arterial occlusions due to thrombi or emboli. Our report highlights the pivotal role of bedside ultrasonography in the emergency diagnosis of acute limb ischemia, exemplified by a case of bilateral femoral arterial occlusion. An 83-year-old woman with a medical history of atrial fibrillation, not on anticoagulation therapy, presented to the emergency department with increased right knee pain and dizziness. Initial examination revealed palpable peripheral pulses and sensitivity on knee palpation without overt signs of ischemia. However, subsequent systemic examination, prompted by the patient’s worsening agitation and pain, revealed coldness, pallor, and weakened pulses in both lower extremities. Bedside ultrasonography confirmed the presence of thrombi in both femoral arteries. The patient underwent successful emergency thrombectomy and was discharged with full recovery after appropriate management of atrial fibrillation. This case underscores the importance of vigilant systemic re-examination and the utility of bedside ultrasonography in the rapid diagnosis of acute arterial occlusion, particularly in patients with risk factors such as atrial fibrillation. Emergency physicians should consider acute limb ischemia in the differential diagnosis of patients presenting with non-specific symptoms like dizziness and localized pain, especially when coupled with a history of cardiovascular risk factors.

Preoperative vascular assessment of patients with a supracondylar humeral fracture and a perfused, pulseless limb

The 'pink, pulseless hand' is often used to describe the clinical situation in which a child with a supracondylar fracture of the humerus has normal distal perfusion in the absence of a palpable peripheral pulse. The management guidelines are based on the assessment of perfusion, which is difficult to undertake and poorly evaluated objectively. The aim of this study was to review the available literature in order to explore the techniques available for the preoperative clinical assessment of perfusion in these patients and to evaluate the clinical implications. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered prospectively with the International Prospective Register of Systematic Reviews. Databases were explored in June 2022 with the search terms (pulseless OR dysvascular OR ischaemic OR perfused OR vascular injury) AND supracondylar AND (fracture OR fractures). A total of 573 papers were identified as being suitable for further study, and 25 met the inclusion criteria for detailed analysis. These studies included a total of 504 patients with a perfused, pulseless limb associated with a supracondylar humeral fracture. Clinical examination included skin colour (23 studies (92%)), temperature (16 studies (64%)), and capillary refill time (13 studies (52%)). Other investigations included peripheral oxygen saturation (SaO2) (six studies (24%)), ultrasound (US) (14 (56%)), and CT angiogram (two studies (8.0%)). The parameters of 'normal perfusion' were often not objectively defined. The time to surgery ranged from 1.5 to 12 hours. A total of 412 patients (82%) were definitively treated with closed or open reduction and fixation, and 92 (18%) required vascular intervention, ranging from simple release of entrapped vessels to vascular grafts. The description of the vascular assessment of the patient with a supracondylar humeral fracture and a pulseless limb in the literature is variable, with few objective criteria being used to define perfusion. The evidence base for decision-making is limited, and further research is required. We were able, however, to make some recommendations about objective criteria for the assessment of these patients, and we suggest that these are performed frequently to allow the detection of any deterioration of perfusion.

RELATO DE CASO: SINDROME DE KLIPPEL-TRENAUNAY

INTRODUCTION: Klippel-Trenaunay syndrome (KTS) is a rare congenital disease, characterized by the triad: capillary malformations that manifest as port wine stain, typically venous varicosities, bone and soft tissue hypertrophy. CASE REPORT: LFRR, term newborn weighing 3360g, male, cesarean delivery due to imminent eclampsia (G3P2C0). Apgar score 9/9 with physical examination showing left lower limb with port wine stain, increased volume and diffuse violaceous lesions extending from the toes to the buttocks, palpable and symmetrical peripheral pulses. DISCUSSION: KTS management does not have a wellestablished consensus, and conservative treatment can be performed using non-invasive measures (elastic or non-elastic compressive stockings) associated or not with psychological support, elevation of the affected limb and physiotherapy. Active conducts such as sclerotherapy can be used in small areas, as well as the use of laser therapy on port wine stains and ulcerations. Sirolimus may be a promising therapeutic option for the management of venous malformations, including KTS, leading to an improvement in symptoms such as pain and a decrease in the size of the lesions. CONCLUSION: KTS, as a rare syndrome, has scarce literature. The main management is based on the use of conservative therapies, others related to the complications presented and now begins the phase of using off-label drugs (Sirolimus) that slow down the progression of the disease.

Clinical Reasoning: An Elderly Woman With a Jugular Bulb Anomaly and Acute Headache.

A 68-year-old woman with a history of type II diabetes mellitus, hypertension, coronary artery disease (s/p coronary angioplasty 2 years before), and right hemiplegia secondary to left internal capsule infarct 1 year before developed central chest pain while on an evening walk. She took a tablet of glyceryl trinitrate (GTN) sublingually, which relieved her chest pain instantly. However, she developed an acute severe throbbing headache, which started behind her left ear and abruptly spread to her entire head. Within a few minutes, the headache peaked in intensity. The headache was associated with tinnitus in her left ear and a vertiginous sensation. She had no vomiting, conjunctival injection, lacrimation, photophobia, or phonophobia. Her headache did not improve with oral analgesics, and she had no history of migraine or other headache types. She reported episodic tinnitus and fullness in the left ear for 1 year. She was taking metoprolol, aspirin, atorvastatin, and telmisartan tablets. Before this episode, she had never taken sublingual GTN that was prescribed for chest pain. On examination, her pulse rate was 100 beats per minute and regular with palpable peripheral pulses. Her blood pressure was 140/90 mm Hg. She had a mild residual right facial palsy. The remainder of her clinical examination was normal.

P0706 / #858: TROMBOTIC MICROANGIOPATHY IN AN INFANT WITH SEPSIS AND FATAL OUTCOME: CASE REPORT

Aims & Objectives: A 1 year-old- female previously healthy and with no history of recurrent infections or previous hospital admissions reported a total of 30 vomits over 3 days prior to presentation. She visited a local hospital in Xilotepec, state of Mexico and an arterial blood gas report: pH 7.10, pco2 9, po2 97, hco3 3, glucose 30 mg/dl. She was treated with IV fluids, glucose and bicarb and she was transferred to our hospital. Upon admission she was with poor neurologic response, HR 174 bpm, tachypneic (55 breaths per minute), with no palpable peripheral pulses, cool extremities, and dry oral mucosa, aggressive IV fluids was started. The analysis of arterial blood gas revealed: hco3 of 4.1 DB -22.2, CO2 14, Anion Gap 46, lactate 1.7. Bicarbonate correction, broad spectrum antibiotics and orotracheal intubation was performed. Toxic etiology was discarded and she was admitted to PICU. Methods: During PICU she required inotropic and vasopressor support, as well as bicarb infusion up to 100 mEqkg due to persistence of severe metabolic acidosis, she developed renal failure that was treated with diuretics. Results: At 24 hours of admission she presented in hands and legs with necrotic lesions which was managed with enoxaparin and pentoxifylline. Blood culture, serology for hepatitis B and hepatitis C were negative. Chest X ray and echocardiography was normal.Conclusions: She was extubated on day 8 and transferred to ward on day 21, she was readmitted 3 days before with refractory septic shock and the patient finally died 12 hours after readmission.

Ankle Brachial Index vs Transcutaneous Partial Pressure of Oxygen for Predicting Healing of Diabetic Foot Ulcers with Peripheral Arterial Disease: a Comparative Study

Foot ulcer is a common complication of diabetes mellitus. The co-existence of peripheral arterial disease (PAD) increases the risk of non-healing of the ulcer. Ankle brachial index (ABI) and transcutaneous partial pressure of oxygen (TcPO2) are two tests used to assess the vascularity of the foot, using two different parameters. This study was done to compare the sensitivity, specificity and diagnostic accuracy of ABI and TcPO2 and to find out which of these is a better predictor of healing in diabetic foot ulcers in patients without palpable foot pulses. The hospital-based longitudinal study was done from March 2016 to March 2018 among 121 adult patients diagnosed with diabetic foot ulcer without palpable peripheral pulses who fit the inclusion and exclusion criteria. Vascularity of the foot in these patients was assessed using ABI and TcPO2. The participants were followed up for 3 months, and the healing status was recorded. The mean (SD) age of patients was 64.99 (10.03) years. Out of 121 patients, 89 were men and 32 were women. The mean ABI in healed and non-healed group were significantly different (P value < 0.001). TcPO2 also showed significant difference in healed and non-healed groups (P value < 0.001). The values of 0.65 in receiver operating characteristic (ROC) curve showed optimal sensitivity (86.1%) and specificity (75.5%) for ABI. ROC curve with a TcPO2 cut-off value of 27.5 mmHg had optimal sensitivity (84.7%) and specificity (81.6%). Although sensitivity of TcPO2 and ABI is comparable (84.7% v 86.1%), specificity and diagnostic accuracy are better for TcPO2.

COVID-19 and Brachial Artery Shotgun Injury

A 77 year old man quarantined with his COVID-19 positive family developed respiratory symptoms and attempted suicide. Trauma computed tomography showed multiple shot pellets in the chest and left arm (A, B); angiography was inconclusive because of metal artefact. Diminished radial and missing ulnar pulses were noted. Emergency surgery in a dedicated COVID-19 operation room showed a single penetration injury of the proximal brachial artery with thrombosis. Soft tissue exploration, Fogarty catheter thrombectomy, sutured arterial repair, and fasciotomy were performed. After COVID-19 confirmation, follow up imaging was omitted (palpable peripheral pulses and preserved upper limb function). The patient is stable, with intermittent nasal oxygen at the COVID-19 care unit.Image 1

A "Blinking" Left Ventricular Assist Device

A 61-year-old male with history of coronary artery disease and end stage ischemic cardiomyopathy underwent a successful implantation of a HeartMate 3 device with an uneventful recovery. However, after 6 months, he complained of increased fatigue, intermittent dizziness, and weakness after minor exertion. The pulsatility index was increased to 8, but the left ventricular assist device (LVAD) was otherwise functioning properly. No major changes in either medications or laboratory results were noted. The patient started getting low flow alarms seven months after the procedure and the dizziness increased. On the controller, a continuously changing (“blinking”) speed was noted (Supplemental Video 1). There was a palpable peripheral pulse and a measurable systolic and diastolic systemic pressure of 105/70 mmHg. There were no signs of hemolysis. The patient was admitted for observation, and a transesophageal echocardiogram was obtained (Supplemental Video 2). The main findings included: 1. Partially recovered left ventricle with ejection fraction 40-45% 2. Small left ventricular cavity with the inflow cannula touching the septum on every other beat 3. Hypokinetic and moderately enlarged right ventricle. After decreasing the speed of the LVAD to from 5200 revolutions per minute to 4800 and giving oral and intravenous fluids, the situation improved. Unfortunately, the symptoms did not completely resolve, and the patient remains admitted to await a cardiac transplantation. This case demonstrates an unusual pattern of a “blinking” LVAD speed due to left ventricular recovery with a small cavity and frequent suctions.

Prognostic Role of Ankle-Brachial Index on Cardiac Damage After Carotid Artery Endarterectomy

Introduction: Carotid endarterectomy (CEA) has been associated with an increased risk for postoperative myocardial ischemia.1 Furthermore, ankle-brachial index (ABI) has been proved to be an independent risk predictor for acute coronary events in patients with known coronary artery disease.2 However, studies evaluating the association between ABI and postoperative cardiac injury in patients undergoing vascular surgery are limited. Therefore, this study aimed to investigate a possible association between ABI and cardiac damage in patients undergoing CEA. Methods: This is a prospective clinical trial that included patients undergoing CEA for symptomatic or asymptomatic carotid artery disease. Only patients with palpable peripheral pulses of the lower extremities were included in the trial. All patients were classified into two groups: Group A (ABI ≥ 0.9) and Group B (ABI< 0.9). Patients with ABI < 0.7 and ABI > 1.3 were excluded. High-sensitivity cardiac Troponin-I (Hs-cTnI) was measured preoperatively and on the 1st and 3rd postoperative day. Cardiac damage was defined as myocardial ischemia (Hs-cTnI>40pg/ml; ABBOTT Architect®) or myocardial infarction (Hs-cTnI>40pg/ml + electrocardiographic changes or clinical symptoms).3 Results: Overall, 107 patients were included in this study (Group A: n=85; Group B; n=22). Regarding basic characteristics, only type IV carotid plaques were more frequent in Group B compared to Group A (75% versus 15%; p = 0.0003). In Group A, 4 patients presented with myocardial ischemia and 2 with infarction postoperatively although only 2 patients presented with ischemia in Group B (P = 0.669). However, when we compared troponin values among surgical days, there was a slight increase of troponin levels on the 1st day compared to preoperative levels in Group B (P = 0.049). Multivariate analysis did not reveal any independent prognostic factor for postoperative cardiac damage. Conclusion: It seems that low ABI is associated with a small increase of HS-cTnI levels on the first postoperative day after CEA in patients without signs or history of peripheral artery disease. However, it seems that it is not associated with clinically evident ischemia. Larger series are needed to confirm if ABI could be utilized as a preoperative predicting tool and in other types of vascular surgery.

Combined Less-invasive Surgical and Endovascular Technique to Minimise Operative Trauma and Treat Excessive Aortoiliac Thrombotic Obliteration with Popliteo-crural Involvement and Acute Limb Ischaemia

This article demonstrates a less-invasive combined surgical and endovascular alternative approach in a case in which an excessive thrombotic formation in the infrarenal aorta caused occlusion of the iliac artery and the ipsilateral crural arteries. A 51-year-old man was admitted to the authors’ hospital with symptomatology of acute lower limb ischaemia. He had undergone endovascular treatment with placement of kissing stents in the common iliac arteries 2 years previously. A CT angiography scan revealed an extensive thrombus formation in the entire infrarenal aorta occluding the distal infrarenal aorta, the iliac artery and the crural arteries. He underwent a hybrid approach, with exposure of only the right common femoral artery and over-the-wire embolectomy of the infrarenal aorta and the iliac artery, and after the restoration of the inflow, an embolectomy of the peripheral vessels was carried out. To cover the residual aortic thrombus and to restore the severe in-stent restenosis of the previously deployed bare stents, three covered balloon-expandable stents were deployed in kissing technique. The patient was discharged on the fourth postoperative day with palpable peripheral pulses. Combined surgical and endovascular techniques minimise the operative trauma and length of hospital stay for the patient, successfully restoring the perfusion in a physiological manner.

Anaesthetic concerns with intramyometrial vasopressin during myomectomy

Vasopressin, a potent vasoconstrictor, has often been used intramyometrially to prevent blood loss during surgical management of uterine myomas. Various lethal complications reported with its use include bradycardia, unmeasurable blood pressure, loss of palpable peripheral pulse, marked pallor, arrhythmia, pulmonary oedema and cardiac arrest. We herein report a case of uterine myomas in which intramyometrial vasopressin-induced complications such as bradycardia, absent pulse and marked pallor were observed with very low dose and concentration (i.e. 1.5 U and 0.1 U/ml). This could be attributed to the coexistence of hypertension in our patient. Here, we discuss the anaesthetic concerns with the use of intramyometrial vasopressin and reinforce the need for dogmatic guidelines envisaging the recommended safe dose and concentrations of intramyometrial vasopressin and proper patient selection.

Intramyometrial vasopressin as a haemostatic agent: Is it really safe?

Vasopressin when given intramyometrially during myomectomy results in good surgical haemostasis.[1,2] At the same time, there are published reports of adverse cardiac events following vasopressin injection.[3,4] Resuscitation measures following such adverse cardiac events require understanding of pharmacodynamics of vasopressin administration.[5] We present a case of successful resuscitation of complete heart block following intramyometrial vasopressin injection during myomectomy and the associated implications.

Can a swallowed foreign body cause severe mitral valve regurgitation ?

Very rarely a foreign body in the esophagus may penetrate anteriorly to heart or aorta. Such foreign bodies may cause pericardial effusion and cardiac tamponade. To report that an accidentally swallowed foreign body in the esophagus may penetrate the heart and even cause severe mitral regurgitation. A 20 month old girl previously healthy presented to the emergency department with 3 days history of fever, respiratory distress, vomiting and poor feeding. The mother reported that her child had some choking event almost a week before, when the child was admitted to another hospital where diagnosis was made of myocarditis. Anti-failure medications prescribed. On examination she had palpable peripheral pulses, a pansystolic murmur on the cardiac apex, and hepatomegaly. EKG showed sinus tachycardia with left ventricular hypertrophy. Chest X-ray revealed normal cardiac size with lungs congestion and suspicion of possible foreign body. Echocardiography showed dilatation of the left atrium and of the pulmonary veins, severe mitral regurgitation with an echogenic structure in next to the posterior mitral valve leaflet with consensual moving. Chest CT scan revealed a high-density metallic foreign body inside the heart in correspondence of the left atrio-ventricular junction. The foreign body was removed surgically and proved to be a thin shiny metal bar, 2 cm in length. The mitral valve was completely damaged and was replaced by mechanical valve (Carbomedics 18 mm). The postoperative course was uneventful and patient was discharged home with anti-failure medications (frusemide, captopril) and warfarin. She remained asymptomatic one year after surgery. The process of diagnosing a foreign body in an infant or a toddler, eroding from the esophagus to the heart was very tricky. The diagnosis was suspected by the history of chocking. The x-ray of the chest showed an abnormal structure on the heart shadow, which was further underlined by the echocardiogram suggesting abnormal structure in the heart. Finally CT angio of heart confirmed a metallic foreign body in the left atrium. Happily, MRI was not done; it may have proved disastrous in such a case. The strategy regarding foreign body management either conservative or by its removal either by cardiac catheterization or surgery, depends on location, size of foreign body as well as on whether the patient is symptomatic and in danger to develop further complications. In our case, as the foreign body was in the left atrium and the patient was very critically ill, we opted to remove it by surgery. Moreover, it was thought that patient might need mitral valve repair but unfortunately the valve was so damaged that we opted for mitral valve replacement.

Combined transdiaphragmatic off-pump and minimally invasive coronary artery bypass with right gastroepiploic artery and abdominal aortic aneurysm repair

Patient: Male, 74Final Diagnosis: Abdominal aortic aneurysm (AAA)Symptoms: Palpable abdominal massMedication: —Clinical Procedure: Abdominal aortic aneurysm repairSpecialty: SurgeryObjective:Rare diseaseBackground:Coronary artery disease is common in elderly patients with abdominal aortic aneurysms. Here we report a case of the combination of surgical repair for abdominal aortic aneurysm and off-pump and minimally invasive coronary artery bypass surgery.Case Report:A 74-year-old man who presented at our clinic with chest pain was diagnosed with an abdominal aortic aneurysm. His medical history included right coronary artery stenting. Physical examination revealed a pulsatile abdominal mass on the left side and palpable peripheral pulses. Computed tomography scans showed an infrarenal abdominal aneurysm with a 61-mm enlargement. Coronary angiography revealed 80% stenosis in the stent within the right coronary artery and 20% stenosis in the left main coronary artery. The patient underwent elective coronary artery bypass grafting and abdominal aortic aneurysm repair. Abdominal aortic aneurysm repair and transdiaphragmatic off-pump and minimal invasive coronary artery bypass grafting with right gastroepiploic artery were performed simultaneously in a single surgery.Conclusions:We report this case to emphasize the safety and effectiveness of transdiaphragmatic off-pump and minimally invasive coronary artery bypass surgery with abdominal aortic aneurysm repair. This combined approach shortens hospital stay and decreases cost.

A 50-year-old woman with syncope

A 50-year-old postmenopausal woman with no prior comorbidity, was brought to the emergency department with two weeks history of exertional dyspnoea, syncope and generalised weakness. There was no associated chest pain or cough. She had experienced three episodes of syncope characterised by loss of consciousness, each episode lasting for 2–3 mins. On examination, she was a middle-aged woman with a pulse of 100 beats·min−1, blood pressure of 120/80 mmHg, respiratory rate of 20 breaths·min−1, room air oxygen saturation of 95% and jugular venous pressure within the normal range. Leg veins were prominent with minimal pedal oedema. Respiratory examination revealed an elliptical chest, normal vesicular breathing and occasional wheeze. Cardiovascular examination revealed a right ventricular heave, audible heart sounds with a systolic murmur audible at the tricuspid area and palpable peripheral pulses. The chest radiograph (CXR) from a local hospital is shown in figure 1. Figure 1 Chest radiograph. ### Task 1 What does the chest radiograph demonstrate? ### Answer 1 An electrocardiogram (EKG) revealed right ventricular strain with no evidence of an acute coronary episode. Initial investigations at our hospital showed a haemoglobin level of 14.9 mg·dL−1 (11.5–13.8 mg·dL−1), total white cell count of 13.2×109 cells·L−1 (4.0–10.0×109 cells·L−1) and platelets of 174×109 cells·L−1 (150–400×109 cells·L−1). Arterial blood gases showed pH 7.53, oxygen tension 65.9, carbon dioxide tension 27.2, HCO3- 22.7 …

Künt Travmaya Bağlı Femoral Arter Disseksiyonu: Olgu Sunumu

Intimal damage, contusion, laceration, dissection, pseudoaneursym and arteriovenous fistula may occur in arterial system after blunt trauma. Twenty years old male patient was admitted to the emergency service following room because of a traffic accident. Femoral artery dissection was detected in patient after blunt trauma. Saphenous vein graft interposition to the femoral artery is applied at the portion before the hunters channel. Microembolic spaces are detected in the basal ganglia and left hemisphere on magnetic resonance inspection of the patient developing unconsciousness at the tenth postoperative hour. Consciousness was opened in clinical follow up. The patient with palpable peripheral pulses was transferred to Neurology Clinic with partial neurological deficit. As a result, dissection of the femoral artery can be rarely seen due to blunt trauma. Although there was early signs of ischemia in our patient, it had not forgotten that the findings of ischemia were occurred in later periods. In this letter, we aimed to introduce a case of dissection on the femoral artery caused by blunt trauma and conducing lower extremity ischemia.

Aneurysm of the left atrium in a child with patent ductus arteriosus and mitral valve prolapse

CLINICAL DATA Infant 9 months, 6.5 kg, female with history of dyspnea during feeding and poor weight gain. Born at term weighing 3.2 kg. In the first month, was diagnosed with congenital heart disease with increased pulmonary hemodynamic, being the child sent from her hometown for surgical treatment. Physical examination showed malnutrition with weight below the percentile 3 for age, tachydyspneic, acyanotic and pale. Hyperdynamic precordium with apical impulse deviated to the left and chest bulging to the left. Continuous murmur 3 + / 6 +, with multiple clicks in the left infraclavicular region. Liver 3 cm from the right costal margin. Large and palpable peripheral pulses in all four limbs.

Traumatic mitral valve rupture

A previously healthy 42-year-old man was admitted to our emergency department after a horse had kicked him in his left chest 2 h earlier. At the trauma scene he was conscious but confused and dyspnoeic. A left thoracostomy was performed and he was transferred to our hospital. Upon arrival, he was awake with a heart rate of 120 beats/min, palpable peripheral pulses, normal breath sounds, and bruises across his lower sternum and left ribcage. Shortly after arrival, he became restless with increasing shortness of breath. The systolic blood pressure decreased to 70 mmHg and his heart rate increased to 140 beats/min, while peripheral pulse oximetry indicated significant oxyhaemoglobin desaturation. An endotracheal intubation was performed and the patient developed massive frothy lung oedema fluid. Chest radiography was interpreted as bilateral lung contusion (Fig. 1) and his electrocardiogram showed sinus rhythm, 75 beats/min, with STT depression in inferolateral leads (Fig. 2). Due to progressive hypoxia, mechanical ventilator pressures were increased. His haemodynamic state further deteriorated into pulseless electrical activity requiring high-dose inotropes and two episodes of cardiopulmonary resuscitation. Transthoracic echocardiography was performed but was complicated because of difficulties in obtaining accurate windows and because of the nervous tension in the emergency department resuscitation room. Finally pericardial tamponade was excluded and no other abnormalities were observed, but colour Doppler was not used. The patient was transferred to the ICU with the diagnoses of bilateral lung contusion and possible myocardial contusion. Because of further respiratory deterioration he was placed in a prone position and a transoesophageal echocardiography (TEE) was performed. This time, a massive mitral insufficiency was observed due to a complete avulsion of the anterolateral papillary muscle (Figs. 3 and 4). Mitral valve replacement was readily carried out. Because of massive pulmonary congestion the patient failed to wean from cardiopulmonary bypass and veno-arterial extracorporeal membrane oxygenation (ECMO) was instituted until haemodynamic stabilisation at day 4. Unfortunately, there was no neurological recovery after cessation of sedation and a brain CT scan revealed massive bilateral ischaemic stroke. After excluding other causes for his neurological state, further therapy was withheld and the patient died.

AP027 Resuscitation in EMS-witnessed prehospital traumatic cardiac arrest

Background: Prehospital traumatic cardiac arrest (TCA) is undoubtedly associated with poor prognosis. The subgroup of patients with detectable vital signs (VS) upon Emergency Medical Services (EMS) arrival and a subsequent EMS-witnessed TCA is of special interest, since it might be associated with better outcome. Materials and Methods: Sixty patients with EMS-witnessed prehospital TCA (Male/Female: 45/15, Mean age: 34.0±21.4 years, Median age: 25 years) were managed by EMS physicians in the area of Thessaloniki during a 10-year period (01.01.1995–31.12.2004). All patients had palpable carotid pulse and organized ECG activity upon EMS arrival and suffered a subsequent, at the scene or during transport, EMS-witnessed TCA. Results: Mean EMS arrival time was 8.3±5.5 min. All patients but one, suffered blunt trauma. Palpable peripheral pulse was detected in 22 (36.67%) cases. Initial median GCS score was 6 (3–15). Pupils were found normal sized in 39 (65.0%) and dilated in 21 (35.0%) patients. Pupillary reflexes were present in 21 (35.0%) patients. During cardiopulmonary resuscitation, all patients received Advanced Life Support interventions by means of endotracheal intubation, fluid resuscitation and chest tube drainage as appropriate. In 25 (41.67%) cases, resuscitation efforts were terminated before arrival at hospital. In total, 35 (58.33%) patients exhibited return of spontaneous circulation. Thirty-two (53.33%) of them died, 12 in the Emergency Department, 17 in the Operating Room and 3 in the Intensive Care Unit. Finally, 3 (5.0%) patients survived to hospital discharge, but only 1 (1.67%) – suffering penetrating neck trauma – with full neurological recovery. Autopsy causes of death revealed severe isolated or multiple organ injuries. Conclusions: The results of our study are in accordance to other similar literature studies and confirm the extremely poor survival rate after TCA. Moreover, resuscitation, even in EMS-witnessed TCA, seems to be in the majority of the cases futility.