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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

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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 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 patient 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 - Coma 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 shock 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 patients 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 Hospital 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 hypotension 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. Catheter-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 surgery <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 catheters cesp.2015.11.009. were introduced, and an infusion of 6 ver, advanced life support 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
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