The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.09.014
Visual Diagnosis in Emergency Medicine
SKIN COLOR CHANGE WITH CIRCULATORY ASSIST DEVICES: SUPERIOR VENA CAVA SYNDROME Atsushi Mizuno, MD, Taku Asano, MD, and Koichiro Niwa, MD Department of Cardiology, Cardiovascular Center, St. Luke’s International Hospital, Tokyo, Japan Reprint Address: Atsushi Mizuno, MD, Department of Cardiology, St. Luke’s International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo 1040043, Japan
upper part of body led to the suspicion of acute superior vena cava (SVC) syndrome, although we could not find the exact cause of SVC syndrome despite insertion of the ECMO venous cannula. Transthoracic echocardiography could not clearly visualize the heart and vessels due to a poor echocardiographic window, but transesophageal echocardiography showed pericardial effusion and collapse of the right ventricle and both left and right atria. We could not find any thrombus in the right atrium or clearly visualize the SVC (Figure 3A). We performed emergency pericardiocentesis, and the skin color returned to normal after 600 mL of blood was removed from the pericardial space, and echocardiography showed restoration of the right heart and left atrial cavities (Figures 2B, 3B).
CASE REPORT An 82-year-old man with hypertension was admitted to our hospital after loss of consciousness. Electrocardiogram showed complete atrioventricular block and ST-segment elevation in the inferior leads (Figure 1A). We diagnosed him with ST-segment elevation inferior myocardial infarction. He collapsed during transfer to the catheterization laboratory and was diagnosed with pulseless electrical activity. We performed cardiac massage, intubated him, and initiated venous-arterial extracorporeal membrane oxygenation (V-A ECMO) and intra-aortic balloon pumping (IABP). Coronary angiography showed severe stenosis in the right coronary artery and total occlusion in the left anterior descending artery (Figure 1B, C). We performed primary coronary intervention in the right coronary artery (Figure 1D). After moving him to the intensive care unit, we noticed a reddening of his skin (Figure 2A). Skin color changes were localized to the upper side of the body, including the face, both arms, and along the diaphragm. These changes were easily blanchable. His blood pressure was brought to 125/61 mm Hg by IABP, and his pulse rate was 104 beats/min. The ECMO flow was 2.5–3.0 L/min and could not be increased despite large amounts of saline infusion and transfusion. The edematous change impeded visual neck vein examination; however, redness of the
DISCUSSION Skin color change in patients with extracorporeal membrane oxygenation has not been previously reported. Redness of the skin, especially on the upper body, helps in diagnosing the extremely elevated venous pressure observed in SVC syndrome (1,2). Previous reports have also shown localized hematoma-induced SVC syndrome (3). We suspected that the pericardial hemorrhage in this case was caused by chest compression. Chest
RECEIVED: 2 March 2014; FINAL SUBMISSION RECEIVED: 26 June 2014; ACCEPTED: 2 September 2014 1
2
A. Mizuno et al.
Figure 1. (A) A 12-lead electrocardiogram. Complete atrioventricular block and ST-segment elevation in the inferior lead, and significant ST-segment depression in the other lead. (B) Coronary angiography. Total occlusion of the left anterior descending artery (white arrow). (C) Right coronary artery shows significant stenosis (arrow heads), which was jeopardized collateral artery to left descending artery. (D) Right coronary artery after stenting, which improved collateral flow to left anterior descending artery.
compressions should be performed on the lower half of the sternum, because the pericardial sac is positioned behind the sternum and close to the SVC (4–7). We suspected that a hematoma might have compressed the interpericardial space of the SVC or upper part of the right atrium directly. Disturbance of blood suction by ECMO resulted in SVC syndrome. Massive pericardial effusion is a life-threatening condition usually detected prior to the onset of SVC syndrome. In our case, ECMO and IABP temporarily preserved perfusion to the systemic circulation, masking the classic signs of cardiac tamponade (for
example, pulsus paradoxus) (8). Unusual elevation of the right atrium and SVC would have been prevented if suction with the ECMO venous cannula had been effective. This case is important because we would not have suspected pericardial hematoma at the initial examination had there been no skin color changes. In summary, caution should be exercised when skin color changes accompany the use of circulatory assist devices such as ECMO and IABP, and echocardiography is recommended to detect pericardial hematoma.
Figure 2. (A) Skin color changes involve broad erythema on the upper body prior to pericardiocentesis. Arrow indicates the border of the skin erythema, which clearly demarcates the upper body. (B) After pericardiocentesis, skin erythema improved immediately.
SVC syndrome on V-A ECMO
3
Figure 3. Transesophageal echocardiography shows the four chambers of the heart. (A) A small amount of pericardial effusion that totally compresses the right atrium and ventricle. (B) After pericardiocentesis, there is no residual pericardial fluid and the right atrial and right ventricular cavities are restored. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
REFERENCES 5. 1. Jansen T, Romiti R, Messer G, Stucker M, Altmeyer P. Superior vena cava syndrome presenting as persistent erythematous oedema of the face. Clin Exp Dermatol 2000;25:198–200. 2. Khouzam RN. Positional skin color changes helping in the diagnosis of superior vena caval obstruction syndrome. J Emerg Med 2011;40: 547–548. 3. Pierli C, Iadanza A, Del Pasqua A, Fineschi M. Acute superior vena cava and right atrial tamponade in an infant after open heart surgery. Int J Cardiol 2002;83:195–197. 4. Shin J, Rhee JE, Kim K. Is the inter-nipple line the correct hand position for effective chest compression in adult
6. 7. 8.
cardiopulmonary resuscitation? Resuscitation 2007;75:305– 310. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S685–705. Choe YH, Im JG, Park JH, Han MC, Kim CW. The anatomy of the pericardial space: a study in cadavers and patients. AJR Am J Roentgenol 1987;149:693–697. Forauer AR, Dasika NL, Gemmete JJ, Theoharis C. Pericardial tamponade complicating central venous interventions. J Vasc Interv Radiol 2003;14:255–259. Spodick DH. Acute cardiac tamponade. N Engl J Med 2003;349: 684–690.
http://dx.doi.org/10.1016/j.jemermed.2014.09.014
Visual Diagnosis in Emergency Medicine
SKIN COLOR CHANGE WITH CIRCULATORY ASSIST DEVICES: SUPERIOR VENA CAVA SYNDROME Atsushi Mizuno, MD, Taku Asano, MD, and Koichiro Niwa, MD Department of Cardiology, Cardiovascular Center, St. Luke’s International Hospital, Tokyo, Japan Reprint Address: Atsushi Mizuno, MD, Department of Cardiology, St. Luke’s International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo 1040043, Japan
upper part of body led to the suspicion of acute superior vena cava (SVC) syndrome, although we could not find the exact cause of SVC syndrome despite insertion of the ECMO venous cannula. Transthoracic echocardiography could not clearly visualize the heart and vessels due to a poor echocardiographic window, but transesophageal echocardiography showed pericardial effusion and collapse of the right ventricle and both left and right atria. We could not find any thrombus in the right atrium or clearly visualize the SVC (Figure 3A). We performed emergency pericardiocentesis, and the skin color returned to normal after 600 mL of blood was removed from the pericardial space, and echocardiography showed restoration of the right heart and left atrial cavities (Figures 2B, 3B).
CASE REPORT An 82-year-old man with hypertension was admitted to our hospital after loss of consciousness. Electrocardiogram showed complete atrioventricular block and ST-segment elevation in the inferior leads (Figure 1A). We diagnosed him with ST-segment elevation inferior myocardial infarction. He collapsed during transfer to the catheterization laboratory and was diagnosed with pulseless electrical activity. We performed cardiac massage, intubated him, and initiated venous-arterial extracorporeal membrane oxygenation (V-A ECMO) and intra-aortic balloon pumping (IABP). Coronary angiography showed severe stenosis in the right coronary artery and total occlusion in the left anterior descending artery (Figure 1B, C). We performed primary coronary intervention in the right coronary artery (Figure 1D). After moving him to the intensive care unit, we noticed a reddening of his skin (Figure 2A). Skin color changes were localized to the upper side of the body, including the face, both arms, and along the diaphragm. These changes were easily blanchable. His blood pressure was brought to 125/61 mm Hg by IABP, and his pulse rate was 104 beats/min. The ECMO flow was 2.5–3.0 L/min and could not be increased despite large amounts of saline infusion and transfusion. The edematous change impeded visual neck vein examination; however, redness of the
DISCUSSION Skin color change in patients with extracorporeal membrane oxygenation has not been previously reported. Redness of the skin, especially on the upper body, helps in diagnosing the extremely elevated venous pressure observed in SVC syndrome (1,2). Previous reports have also shown localized hematoma-induced SVC syndrome (3). We suspected that the pericardial hemorrhage in this case was caused by chest compression. Chest
RECEIVED: 2 March 2014; FINAL SUBMISSION RECEIVED: 26 June 2014; ACCEPTED: 2 September 2014 1
2
A. Mizuno et al.
Figure 1. (A) A 12-lead electrocardiogram. Complete atrioventricular block and ST-segment elevation in the inferior lead, and significant ST-segment depression in the other lead. (B) Coronary angiography. Total occlusion of the left anterior descending artery (white arrow). (C) Right coronary artery shows significant stenosis (arrow heads), which was jeopardized collateral artery to left descending artery. (D) Right coronary artery after stenting, which improved collateral flow to left anterior descending artery.
compressions should be performed on the lower half of the sternum, because the pericardial sac is positioned behind the sternum and close to the SVC (4–7). We suspected that a hematoma might have compressed the interpericardial space of the SVC or upper part of the right atrium directly. Disturbance of blood suction by ECMO resulted in SVC syndrome. Massive pericardial effusion is a life-threatening condition usually detected prior to the onset of SVC syndrome. In our case, ECMO and IABP temporarily preserved perfusion to the systemic circulation, masking the classic signs of cardiac tamponade (for
example, pulsus paradoxus) (8). Unusual elevation of the right atrium and SVC would have been prevented if suction with the ECMO venous cannula had been effective. This case is important because we would not have suspected pericardial hematoma at the initial examination had there been no skin color changes. In summary, caution should be exercised when skin color changes accompany the use of circulatory assist devices such as ECMO and IABP, and echocardiography is recommended to detect pericardial hematoma.
Figure 2. (A) Skin color changes involve broad erythema on the upper body prior to pericardiocentesis. Arrow indicates the border of the skin erythema, which clearly demarcates the upper body. (B) After pericardiocentesis, skin erythema improved immediately.
SVC syndrome on V-A ECMO
3
Figure 3. Transesophageal echocardiography shows the four chambers of the heart. (A) A small amount of pericardial effusion that totally compresses the right atrium and ventricle. (B) After pericardiocentesis, there is no residual pericardial fluid and the right atrial and right ventricular cavities are restored. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
REFERENCES 5. 1. Jansen T, Romiti R, Messer G, Stucker M, Altmeyer P. Superior vena cava syndrome presenting as persistent erythematous oedema of the face. Clin Exp Dermatol 2000;25:198–200. 2. Khouzam RN. Positional skin color changes helping in the diagnosis of superior vena caval obstruction syndrome. J Emerg Med 2011;40: 547–548. 3. Pierli C, Iadanza A, Del Pasqua A, Fineschi M. Acute superior vena cava and right atrial tamponade in an infant after open heart surgery. Int J Cardiol 2002;83:195–197. 4. Shin J, Rhee JE, Kim K. Is the inter-nipple line the correct hand position for effective chest compression in adult
6. 7. 8.
cardiopulmonary resuscitation? Resuscitation 2007;75:305– 310. Berg RA, Hemphill R, Abella BS, et al. Part 5: adult basic life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S685–705. Choe YH, Im JG, Park JH, Han MC, Kim CW. The anatomy of the pericardial space: a study in cadavers and patients. AJR Am J Roentgenol 1987;149:693–697. Forauer AR, Dasika NL, Gemmete JJ, Theoharis C. Pericardial tamponade complicating central venous interventions. J Vasc Interv Radiol 2003;14:255–259. Spodick DH. Acute cardiac tamponade. N Engl J Med 2003;349: 684–690.
