Emergencias 2016;28:136-140

LETTERS TO THE EDITOR Emergent percutaneous in the coronary care unit and then five Pediatric chest injuries: take days in a ward, with good evolution. intervention in submassive On the fifth day, control CT showed care on detecting a heart pulmonary embolism with thrombus resolution and normalization murmur contraindications for of right ventricular function. At 3 systemic thrombolysis months of follow-up the was as - Traumatismo torácico en pediatría: ymptomatic and treated with oral anti - atención a la aparición de un soplo coagulation. Tratamiento percutáneo urgente del Percutaneous treatment is an al - To the editor: embolismo pulmonar submasivo ternative to ST in cases of massive con contraindicaciones de A 6 year-old boy was taken to the ED and sub-massive PE with indica - after falling from the fifth floor. Glasgow trombolisis sistémica tions for reperfusion, but with ab - Scale score was 14 points (O3, V5, solute or relative contraindications M6) and vital signs were stable. The pu - To the editor: for ST 1. A purely mechanical, phar - pils were symmetrical and reactive to Pulmonary embolism (PE) has a macological approach (selective re - light. He had bruises and abrasions on broad spectrum of severity from as - the anterior chest wall and extensive bo - lease thrombolytic), or both can be ymptomatic cases to or car - ne and soft tissue lesions on the chest. adopted. The procedure is success - diac arrest. Risk stratification is re - Cardiac auscultation indicated a rough ful in 86.5% (massive PE) and commended using the Pulmonary pansystolic, grade 4/6 murmur that soun - 97.3% (sub-massive PE), with rates Embolism Severity Index (PESI). In ded stronger on the lower left sternal of major bleeding greater than 3% border. Cardiac enzymes were elevated, cases of massive or sub-massive PE (none intracranial) and 0% respec - with a peak creatine kinase MB (CK-MB) with high-risk criteria, treatment tively 2,3 . Organizing teams of inter - >300.0 (normal range <3.4 ng/ml) and with systemic thrombolysis (ST) 1 is ventional cardiologists for primary troponin I >50.0 (normal range < 0.1 recommended. However, about angioplasty makes this technique ng/ml). The electrocardiogram showed one-third of have relative persistent sinus tachycardia. Transthoracic available in a growing number of or absolute contraindications for echocardiography showed interventricular centers 4. ST. trabecular rupture with two traumatic ventricular septal defects (VSD), interven - A 74 year-old man attended the ED Pablo Salinas, tricular short circuit from left to right (Fi - for a presyncopal episode and dyspnea. Iván Núñez-Gil, gure 1), and septal dyskinesia. According He had been operated 40 days before Sandra Rosillo, to the family and pediatric medical re - for lumbar discectomy and arthrodesis Antonio Fernández-Ortiz cords, the child had no history of heart and on the seventh day voluntarily inte - Servicio de Cardiología, Instituto Cardiovascular, murmur. Two months after the initial rrupted the treatment with enoxaparin Clínico San Carlos, Madrid, Spain. event, scheduled open repair of the VSD despite prolonged immobilization. [email protected] was performed and today the patient is Physical examination in the ED showed well. pallor and coldness, respiratory rate of 25 rpm, heart rate of 105 bpm, blood Trauma is the leading cause of pressure 90/50 mmHg and 97% O2 sa - morbidity and mortality in children turation (FiO2 28%). The electrocardio - Conflict of interest worldwide 1. Cardiac injury in chil - gram showed sinus tachycardia, right The authors declare no conflict of interest related to this article. dren after blunt chest trauma is bundle branch block. Urgent computed 2 tomography (CT) showed extensive PE 4.6% . VSD of traumatic causes are with overloaded right cavities. Blood extremely rare and easily missed but tests showed lactate 2.4 mg/dl; Tropo - can be life-threatening. Clinical trau - nin I 0.83 ng/ml (0.05 ng p99/ml), matic VSD findings are nonspecific, NTproBNP 4715 pg/ml and D-dimer References can be masked by other injuries, and 32,754 ng/ml. Emergency echocardio - clinical manifestations can often be 1 Konstantinides SV, Torbicki A, Agnelli G. gram showed dilation and acute right 3 2014 ESC guidelines on the diagnosis and delayed . Furthermore, in a patient ventricular dysfunction. It was classified management of acute pulmonary embolism. with multisystem traumatic injuries, as submassive PE with high intermedia - Eur Heart J. 2014;35:3033-69. persistent is usually at - te risk criteria [troponin, NT-proBNP, 2 Kuo WT, Gould MK, Louie JD, Rosenberg JK, tributed to blood loss. It is also easy right dysfunction, PESI class IV (114 Sze PY, Hofmann LV. -directed the - points)]. He was admitted to the coro - rapy for the treatment of massive pulmonary to miss a heart murmur during aus - nary care unit and sodium heparin infu - embolism: systematic review and meta- cultation in a noisy environment, sion was initiated. The initial outcome analysis of modern techniques. J Vasc Interv typical during attention of a multiple was poor (oliguria, signs of low cardiac Radiol. 2009;20:1431-40. injury emergency. 3 Kuo WT, Banerjee A, Kim PS, DeMarco FJ, output, increased lactate), so reperfu - Levy JR, Facchini FR, et al. Pulmonary Embo - Currently, there is no a standard sion was considered. Although there lism Response to Fragmentation, Embolec - reference for the diagnosis of trau - were no absolute contraindications for tomy, and Catheter Thrombolysis (PERFECT): 1 matic cardiac injury in children nor is thrombolysis (major <3 weeks) , Initial Results From a Prospective Multicenter there a management algorithm that we considered that the recent surgery Registry. Chest. 2015;148:667-73. was a relative contraindication for ST; 4 Sánchez-Recalde A, Moreno R, Estebanez Flores is widely accepted. Most diagnostic so percutaneous treatment by aspira - B, et al. Tratamiento percutáneo de la trombo - tests are not specific, and few studies tion and thrombus fragmentation was embolia pulmonar aguda masiva. Rev Esp Car - focus on the characteristics of the diol 2016. http://dx.doi.org/10.1016/j.re - physical exam in children 4. Moreo - performed. Subsequently, two cesp.2015.11.009. were introduced, and an infusion of 6 ver, advanced guidelines mg rtPA was left 24 h in each lung for multi trauma patients do not em - branch. The patient remained 48 hours phasize the importance of a new car -

136 Emergencias 2016;28:136-140

4 Langer JC, Winthrop AL, Wesson DE, Spence of victims, the injury pattern produ - L, Pearl RH, Hoffman MA et al. Diagnosis ced by firearms for military use over and incidence of cardiac injury in children with blunt thoracic trauma. J Pediatr Surg. short distances directed at grouped 1989;24:1091-4. victims should make us reflect on the 5 American College of Surgeons Committee on most suitable system of triage, pre - Trauma. Thoracic Trauma. Advanced trauma hospital and hospital care, as well as life support for doctors: ATLS student course manual. 8th Edition. Chicago, IL: American evacuation and transport of the College of Surgeons; 2008. pp. 85-101. wounded. These patients have a dif - ferent pattern from those that have been wounded by a bomb 4 and are likely to benefit from rapid stabiliza - Terrorist attacks and tion of life-threatening injuries, espe - cially external bleeding in this case, emergency medical services: and rapid transfer to a surgical treat - time for reflection ment center. For the prehospital tria - ge of these patients there are tools Atentados terroristas y servicios such as Advanced Triage out-of-hos - médicos de emergencia: tiempo para pital Model (ATEM), which allows ra - la reflexión pid clinical assessment and early diagnosis of critical potentially surgi - 5 Figure 1. Ultrasound showing rupture To the editor: cal injuries . of the interventricular septum (arrows). For the field of emergency medi - Terrorism is an increasing global cal services (EMS), the recent terro - phenomenon showing different epi - rist attacks in Paris in November demiological profiles according to 2015 are reason to reflect on the geographical areas. Its global study diac murmur 5 in the evaluation of scope and adequacy of planning our should enable health system analysis chest injuries. response to these incidents. Al - of trends and planning health res - The trauma team leader should though medical health response to ponse adapted to changing patterns be alert to the possibility of a new an incident with multiple victims has of impact because, in the future, te - heart murmur after chest trauma. Its complex organizational and health - rrorist attacks in Europe are likely to appearance should be considered as care peculiarities, terrorist attacks ha - have a different profile than those a possible traumatic VSD. An the ve added elements that should be currently observed in the more com - bedside, it is feasible to use a combi - especially considered 1. The specifics monly affected areas, such as Central nation of diagnostic tools such as a are related with the following as - Asia, Middle East or Africa. 12-lead ECG, determination of car - pects: (i) clinical management of vic - diac enzymes and a 2D echocardio - tims; (ii) safety at the scene; and (iii) gram. In our case, traumatic VSD prehospital and hospital coordina - Rafael Castro Delgado 1,2 , was diagnosed within the first 3 tion. Pedro Arcos González 1, hours of arrival at hospital and was Recent epidemiology of terrorist Tatiana Cuartas Álvarez 1,2 properly treated. attacks 2 show that the most common 1Unidad de Investigación en Emergencia y type is by a bomb or other explosive Desastre, Departamento de Medicina, Universidad 2 device as the mechanism of damage. de Oviedo, España. SAMU-Asturias UME-3, Avilés, Spain. Fay Li Xiangzhen, This fact, and in the particular case Yee Ling Cheong, of Spain since the Madrid bombings, [email protected] Jonathan Tze Liang Choo, Narasimhan Kannan Laksmi has made EMS review and adapt their procedures to deal with these Department of Paediatric Surgery, KK Women’s and Conflict of interest Children’s Hospital, Singapore. incidents based on the above pecu - The authors declare no conflict of interest related to this article. [email protected] liarities. On the other hand, some data has alerted us to new forms of terrorism in Europe, and the events References Conflict of interest in Paris have corroborated the gro - wing trend in the frequency of hos - The authors declare no conflict of interest 1 Arcos González P, Castro Delgado R. (Dirs.). related to this article. tage taking (4 times more in 2014 Terrorismo y Salud Pública. Gestión sanitaria than the average for the period de atentados terroristas con múltiples vícti - 1970- 2013), the average mortality mas por bomba. Madrid: Ministerio de Sani - and increased use of fire weapons 3. dad y Consumo - FCSAI; 2007. References 2 The Global Terrorism Database. U.S. Depart - This scenario introduces new ele - ment of Homeland Security and University of 1 Bliss D, Silem M. Pediatric thoracic trauma. ments to consider. Firstly, regarding Maryland, 2015. (Consultado: 1 Febrero 2016). Crit Care Med. 2002;30:409-15. safety, a group of terrorists moving Disponible en: http://www.start.umd.edu/gtd/ 2 Liedtke AJ, DeMuth WE Jr. Non-penetrating through a city impedes the deploy - 3 START National Consortium for the Study of cardiac injuries: Collective r review. Am He - Terrorism and Responses to Terrorism. Over - art J. 1973;86:687-97. ment of advanced medical posts in view: Terrorism in 2014 (background re - 3 Dowd MD, Krug S. Pediatric blunt cardiac the area for obvious safety reasons, port). Agosto, 2015. (Consultado 15 Diciem - injury: epidemiology, clinical features, and which means rethinking the current bre 2015). Disponible en: http://www.start. diagnosis. Pediatric Emergency Co - predominant model of health res - umd.edu/pubs/START_GTD_OverviewofTe - llaborative Research Committee: Working rrorism2014_Aug2015.pdf?utm_source=STAR Group on Blunt Cardiac Injury. J Trauma. ponse to terrorist attacks in Spain. T+Announce&utm_campaign=dde8d14b29- 1996;40:61-7. Regarding the clinical management Contextualizing+the+Paris+Attacks&utm_me -

137 Emergencias 2016;28:136-140

dium=email&utm_term=0_a60ca8c769- dde8d14b29-14077645 4 Peleg K, Aharonson-Daniel L, Michael M, Sha - pira SC. Patterns of injury in hospitalized terro - rist victims. Am J Emerg Med. 2003;21:258-62. 5 Arcos González P, Castro Delgado R. (Dirs.). El Modelo Extrahospitalario de Triage Avanzado (META) para incidentes con múltiples vícti - mas. Madrid: Instituto de Prevención, Salud y Medio Ambiente. Madrid: Fundación MAP - FRE; 2011.

Electrocardiography artifacts simulating ventricular tachycardia

Artefactos electrocardiográficos simulando una taquicardia ventricular

To the editor: Electrocardiographic artifacts simu - lating ventricular tachycardia (EASVT) are limited to isolated cases and series Figure 1. Telemetry recording initially interpreted as VT. The spike sign indicated by of patients bearing a portable electro - circles is one of the 3 characteristic signs allowing a diagnosis of EASVT cardiograph monitor or pacemaker 1-4 . The error and confusion with ventri - cular tachycardia (VT) leads to diag - mining the record of the pacemaker or Universitario Severo Ochoa, Leganés, Madrid, nostic tests and unnecessary an - 2 Holter and, rarely, a stress test. The Spain. Servicio de Cardiología, Hospital tiarrhythmic drugs as well as Universitario Severo Ochoa, Leganés, Madrid, implantation of cardiac devices. We most important differential characteris - Spain. report the case of a patient admitted tics with true VT are the absence of he - [email protected] to the (ICU) after modynamic deterioration (which can suffering an compatible also rarely occur in a VT), an unstable with VT. electrocardiographic baseline before the episode, sometimes in relation to Conflict of interest A 54 year-old man with a history of outside noise, and the presence of any The authors declare no conflict of interest high cholesterol and smoking was admitted of the following 3 signs: sinus sign, the related to this article. to the ICU after presenting acute coronary sign of the spike and the sign of the syndrome without ST segment elevation 5-7 treated with 2 right coronary artery everoli - notch . The first occurs on recording mus-coated stent implantations. At 48 sinus rhythm in the precordial leads; hours of discharge from the ICU, with no the second when sharp spikes are ob - References symptoms, he presented, recorded by tele - served, with a regular cadence or not, metry, ECG tracings compatible with unsus - and the third when notches within the 1 Knight BP, Pelosi F, Michaud GF, Strickberger tained VT that required re-admission and SA, Morady F. Clinical consequences of electro - artifact are observed, corresponding to cardiographic artefact mimicking ventricular the administration of intravenous amiodaro - native QRS complexes with a certain tachycardia. N Engl J Med. 1999;341:1270-4. ne. Blood tests, including cardiac enzymes, range that matches the length of the 2 Krasnow AZ, Bloomfield DK. Artifacts in por - showed normal values. The electrocardio - simultaneously recorded basal sinus table electrocardiographic . Am gram performed in the ICU showed sinus Heart J. 1976;91:349-57. rhythm with no signs of acute ischemic he - cycle. In our case, the sign of the spike 3 Tarkin JM, Hadjiloizou N, Kaddoura S, Collin - art disease. However, subsequent analysis of can be seen in various leadss. We attri - son J. Variable presentation of ventricular electrocardiographic telemetry revealed buted the cause to movement and in - tachycardia-like electrocardiographic arti - sharp spikes in lead I, II, III, AVF and V1, V5, adequate adhesion of the electrodes to facts. J Electrocardiology 2010;43:691-3. 4 Dyke DBS, Rich PB, Morady F. Wide complex some isolated and irregular and others re - the skin. In conclusion, a high index of tachycardia in a critically ill patient: What is gular in the QRS complex (Figure 1, circles). suspicion and a certain expertise is nee - the rhythm? J Cardiovasc Electrophysiol. This pattern was consistent with EASVT, ded to accurately rule out EASVT, the - 1997;8:1327-8. which allowed discontinuation of IV an - reby preventing and reducing diagnos - 5 Ortega-Carnicer J. Tremor-related artefact tiarrhythmic . Evolution was sa - mimicking ventricular tachycardia. Resuscita - tisfactory, and the patient was transferred to tic tests, invasive or not, therapeutic tion. 2005;65:243-4. the department. maneuvers and unnecessary consump - 6 Chun-Yao Huang, Din-E Shan, Chao-Hung tion of health resources. Lai, Man-Cai Fong, Po-Shun Huang, Hsien- Hao Huang et al. An accurate electrocardio - Although EASVT is rare, most occur graphic algorithm for differentiation of tre - as a result of body movements, electro - Miguel Angel Blasco-Navalpotro 1, mor-induced pseudo-ventricular tachycardia magnetic interference, or intermittent Juan Manuel Grande-Ingelmo 2, and true ventricular tachycardia. Intern J skin contact with electrodes 2,3,5 . In ge - José Luis Flordelís Lasierra 1, Cardiol. 2006;111:163-5. Alberto Orejas Gallego 1 7 Lin SL, Wang SP, Kong CW, Chang MS. Arti - neral the diagnosis is made by tele - fact simulating ventricular and atrial arrhyth - metry analysis and sometimes by exa - 1Servicio de Medicina Intensiva, Hospital mia. J Pn Heart J. 1991;32:847-51.

138 Emergencias 2016;28:136-140

Acute traumatic abdominal wall hernia and aortic dissection

Hernia traumática aguda de la pared abdominal asociada a disección aórtica

To the editor: Traumatic abdominal wall hernias are defined as fascial-muscle rupture caused by trauma or skin lesion wi - thout prior hernia. They are a rare complication, but their incidence has been increasing in recent years due to traffic accidents, with high-energy trau - ma estimated frequency of 1%. Its ma - nagement is currently not well defined Figure 1. Computed tomography sho - and highlycomplex 1. wing a post-traumatic hernia. A 38 year-old woman was brought to the ED after a high-energy frontal-lateral car In this case, CT identified the lesion Figure 2. Intraoperative findings: 1. accident in which one of several passengers in the abdominal wall and the aortic complete rupture of abdominal muscles died, all wearing seat belts. During helicop - dissection, although no intestinal le - with dissected epigastric artery. 2. Small ter transfer and on arrival at the hospital the sions were detected. Therefore, the as - bowel lesions. 3. Closure next to the des - lady was hemodynamically stable, but had cending colon. 4. Complete rupture of pain in the lower abdomen. Physical exami - sociation of a traumatic hernia of the nation revealed the "seat belt sign" and a abdominal wall and aortic dissection in the peritoneum and abdominal muscles. slight left flank deformity that appeared to a patient with severe blunt abdominal 5. Distal closure of the descending colon. be a hematoma. Full body CT revealed fo - trauma could be indicative of other in - cal left aorta-iliac dissection in the abdomi - tra-abdominal injuries that cannot be nal region, fracture of the upper plate of tual de las hernias traumáticas de pared ab - seen on imaging tests. This raises the dominal. Cir Esp. 2007;82:260-7. the L4 vertebra, fracture of the 1st left rib, possibility of a laparotomy in a patient 2 Rutledger R, Thomason M, Oller D, Mere - sternoclavicular dislocation, hemoperito - with multiple abdominal injuries and a dith W, Moylan J, Clancy T. The spectrum of neum with possible subcapsular splenic he - history of such severe trauma 5. abdominal injuries associated with the use of matoma and herniation of left flank with seat belts. J Trauma. 1991;31:820-5. evisceration of small bowel loops (Figure 1). Conservative management of trau - 3 Sato TK. Effects of seat belts and injuries resulting Despite hemodynamic stability, surgery was matic hernia may be appropriate in se - from improper use. J Trauma. 1987;27:754-8. required. After placing a stent in the aorta- lected cases, with low risk of complica - 4 Shuman W. CT of blunt abdominal trauma iliac bifurcation, we proceeded to perform in adults. Radiology. 1997;205:297-306. tions (strangulation, etc.) without 5 Ballard DH, Kaskas NM, Jahromi AH, Skweres J, laparotomy, where a hemoperitoneum was other intra-abdominal injuries. If one Youssef AM. Abdominal wall hernia and aortic identified in addition to the complete rup - opts for the deferred treatment, the injury secondary to blunt trauma: case report ture of the left abdominal muscle, which in - hernia size may increase and the su - and review of the literatura. International Jour - cluded internal, external, transverse and rrounding muscles atrophy, which can nal of Surgery Case Reports. 2014;5:1238-41. part of left rectus oblique muscles. An entire 6 6 Yadav S, Jain SK, Arora JK, Sharma P, Sharma section of the descending colon was seen, hinder surgical repair . Urgent repair of A. Traumatic abdominal wall hernia. Delayed with a complete disruption of the mesen - the hernia defect in a primary anato - repair: advantageous or taxing. International tery in about 50 cm of distal ileum and an mical way is recommended, without Journal of Surgery Case Reports. 2013;4:36-9. 7 Lane CT, Cohen AJ, Cinat ME. Management entire section of jejunal loop with involve - placing prosthetic material, if there is of traumatic abdominal wall hernia. Am ment of about 20 cm (Figure 2). The affec - contamination, due to the high risk of Surg. 2003;69:73-6. ted segments were removed and two anas - infection 7. tomoses were performed, and a descending colon stoma was left with a closed distal Enrique Colás Ruiz 1, end. Finally, we proceeded to close the de - Federico Ochando Cerdán 1, Noninvasive mechanical fect of the abdominal wall in several planes Begoña Cajal Campo 2, ventilation in a with loose points. She remained hospitali - José María Fernández Cebrián 1 zed for 28 days in the ICU with good evo - 1Servicio de Cirugía General y Aparato Digestivo, patient with acute lution and was discharged after a week. Hospital Universitario Fundación Alcorcón, Madrid, secondary Spain. 2Servicio de Radiología, Hospital The use of seat belts reduces mor - Universitario Fundación Alcorcón, Madrid, Spain. to massive atelectasis tality, but may increase the presence of [email protected] intra-abdominal injuries, possibly by Ventilación mecánica no invasiva en 2,3 wrong positioning . Traumatic hernias Conflict of interest un paciente politraumatizado con by high-energy accidents are most of - The authors declare no conflict of interest insuficiencia respiratoria aguda ten located along the side of the rectus related to this article. secundaria a una atelectasia masiva muscles in the lower abdomen or groin. Sometimes they are associated References To the editor: with other abdominal injuries, so that Regarding polytrauma patients, CT is a very useful and mandatory test 1 Moreno-Egea A, Gireal E, Parlorio E, Aguayo- few studies focus on the use of no - 4 for early diagnosis . Albasini JL. Controversias en el manejo ac - ninvasive

139 Emergencias 2016;28:136-140

(NIMV). Some studies highlight the importance of NIMV in the manage - ment of patients with severe trauma and acute respiratory failure (ARF), with a decrease in the need for intu - bation of ventilator-associated pneu - monia, and probably mortality 1. In multiple trauma, rib fractures can be associated with multiple complica - tions such as hemothorax, pneumo - Figure 1. Chest radiograph showing the opacification of the left lung and subsequent thorax or secondary complications or resolution with chest drainage and non-invasive ventilation. severe pain that interferes with lung mechanics, hindering ventilation and favoring accumulation of secretions improvement after the extraction of 500 María Fernández González 1, or the appearance of atelectasis. Each cc of serohematic liquid. Control x-ray Ricardo Lucas García-Mayor Fernández 2 can generate a picture of hypoxemic showed exclusion of the left lung and air 1Servicio de Urgencias, Complejo Hospitalario ARF, and compromise the patient's li - in the pleural space (Figure 1). Massive Universitario de Ourense, Spain. 2Servicio de fe. The application of positive pressu - atelectasis of the left lung was suspected Cirugía General y del Aparato Digestivo, Hospital re in the airway is effective in preven - and VMNI was initiated to resolve the do Salnés, Vilagarcía de Arousa, Spain. ARF with BiPAP at low pressure given the [email protected] ting postoperative atelectasis, alone risk of barotrauma (IPAP 10 cm H O, or combined with other physiothe - 2 EPAP 5 cm H 2O), adding nebulization rapy respiratory techniques 2,3 . Once and coverage. With these pres - atelectasis is diagnosed, bronchos - sures the patient achieved a tidal volume Conflict of interest copy is the procedure of choice for of approximately 350 ml, which maintai - The authors declare no conflict of interest related to this article. resolution, but with ARF it is contrain - ned proper ventilation with SpO 2 94% dicated. NIMV to treat lung atelecta - and improved breathing without as - ynchrony. After 20 minutes of VMNI the sis in patients with ARF would there - References 4 patient showed decreased respiratory rate fore constitute an alternative . (RR) below 20 rpm, as well as improved breathing and comfort. X-ray 4 hours af - 1 Antonelli M, Conti G, Rocco M, Bufi M, De A 37 year-old man, smoker, attended ter NIMV showed resolved atelectasis (Fi - Blasi RA, Vivino G, et al. A comparison of the ED of a local hospital due to left gure 1). The patient required sedation noninvasive positive pressure ventilation and chest pain secondary to trauma. Upon with midazolam and morphine chloride conventional mechanical ventilation in pa - arrival he was hemodynamically stable for pain control, achieving excellent tients with acute respiratory failure. N Engl J and eupneic. Chest x-ray and CT scan re - adaptation to NIMV. He improved and Med. 1998;339:429-35. vealed posterior left fractures from the was transferred to the department of tho - 2 Al Jaaly E, Fiorentino F, Reeves BC, Ind PW, 4th to the 9th costal arch with a non-oc - racic surgery at the referral hospital for Angelini GD, Kemp S, et al. Effect of adding clusive subcarinal block of dense mucosa. evolutionary control. postoperative noninvasive ventilation to usual Medical treatment was initiated with care to prevent pulmonary complications in analgesia and expectorant. During his ED patients undergoing coronary artery bypass This case shows that the NIMV is grafting: A randomized controlled trial. J stay, he presented acute pain in the left an effective alternative for the treat - hemithorax and dyspnea with tachypnea Thorac Cardiovasc Surg. 2013;146:912-8. ment of massive atelectasis in pa - 3 Jaber S, Michelet P, Chanques G. Role of (32 bpm) with 88% SpO (PaO 55 2 2 tients with severe trauma who deve - non-invasive ventilation (NIV) in the periope - mmHg) despite O 2 with a mask, and FiO 2 rative period. Best Pract Res Clin Anaesthe - 50%. Chest x-ray showed opacification of lop ARF. Chest drainage allowed NIMV treatment of the massive ate - siol. 2010;24:253-65. the left lung (Figure 1). A chest drain was 4 Mirambeaux R, Mayoralas S, Días S. Resolu - placed in the 5th intercostal space on lectasis more safely, controlling for tion of Obstructive Atelectasis With Non-In - suspected hemopneumothorax with res - the possibility of developing tension vasive Mechanical Ventilation. Arch Bronco - piratory compromise, with partial clinical pneumothorax . neumol. 2014;50:452-3.

140