In normal adults, a pressure of 120 to 150 mm Hg, which corresponds to a volume of 4 L, is required to cause gastric rupture. However, lesser pressure is required if external compression is performed [4]. Both external chest compres- sion and Gastric distension increased intragastric pressure and resulted in gastric perforation during resuscitation. External chest compression compresses the pylorus and cardia against the spine and further prevents gastric emptying. Gastric dilatation in the patient before resuscita- tion may also lead to gastric rupture owing to impaired release-valve function of the pylorus and cardia [5]. This patient illustrates the increased risk of gastric rupture resulting from distended stomach during resuscitation. Primary care physicians should be alert in searching for any intra-abdominal Free air after resuscitation in such high- risk patients.

Pei-ying Lin MD Department of Internal Medicine National Taiwan University Hospital and College of Medicine, Taipei 100, Taiwan

Min-Shan Tsai MD Jia-How Chang MD

Wen-Jone Chen MD, PhD Chien-Hua Huang MD

Department of Emergency Medicine National Taiwan University Hospital and College of Medicine, Taipei 100, Taiwan

E-mail address: [email protected] doi:10.1016/j.ajem.2006.02.009

References

1. Mularski RA, Sippel JM, Osborne ML. Pneumoperitoneum: a review of nonsurgical causes. Crit Care Med 2000;28:2638 - 44.
2. Hargarten KM, Aprahamian C, Mateer J. Pneumoperitoneum as a complication of cardiopulmonary resuscitation. Am J Emerg Med 1988;6:358 - 61.
3. Tung PH, Law S, Chu KM, et al. Gastric rupture after Heimlich maneuver and cardiopulmonary resuscitation. Hepatogastroenterology 2001;48:109 - 11.
4. Millis SA, Paulson D. Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation. Ann Emerg Med 1983;12: 94 - 5.
5. Strear CM, Jarnagin WR, Schecter W, et al. Gastric rupture and tension pneumoperitoneum complicating cardiopulmonary resuscitation: case report. J Trauma 1998;44:930 - 2.

Extracorporeal membrane oxygenation as a bridge to surgical embolectomy in acute fulminant pulmonary embolism

We report an emergency department (ED) resuscitation using extracorporeal membrane oxygenation for multiple massive pulmonary emboli (PE). The patient was a

17-year-old female who presented to a community teaching hospital ED with shortness of breath for 1 week. The day of presentation, the patient acutely worsened and presented via ambulance. The patients’ history included diabetes mellitus, mild asthma, hypertriglyceridemia, and depres- sion. Medications included insulin, albuterol, fenofibrate, and venlafaxine. Notably, her father and grandmother had a history of PE and deep venous thrombosis, respectively. She denied any other PE risk factors.

The following were the initial vital signs: blood pressure 92/50 mm Hg, heart rate 168 beats/min, respiration 48 breaths/min, pulse oximetry 86% on 100% non-rebreather, and temperature 38.2 8C rectally. On physical exam, the patient was in severe respiratory distress, breath sounds were clear and equal bilaterally, tachycardic but normal heart sounds. Significant laboratory results were Serum glucose 725 mg/dL and a positive qualitative D-dimer. Other laboratory results were unremarkable, and an arterial blood gas was not initially done. A portable chest radiograph was normal without infiltrates, and an electro- cardiogram was significant for a sinus tachycardia at 168 beats/min with an S₁Q₃T₃ pattern.

Because of worsening respiratory distress, she was intubated via rapid sequence intubation. A bedside ED ultrasound was performed looking for possible pericardial effusion and was notable for a mobile density in the right atrium and a distended right atrium and ventricle (Fig. 1). Acute PE was suspected as the etiology of the respiratory distress. A Spiral computed tomography was significant for extensive PE and a large thrombus in the right atrium. Upon return to the ED, the patient was administered recombinant tissue plasminogen activator. The patient further decom- pensated requiring multiple episodes of closed chest compressions and advanced cardiac life support. Cardiotho- racic surgery was consulted for embolectomy, but because of her age, it was recommended that the patient be transferred to a pediatric referral center. However, because of her persistent circulatory instability, the cardiothoracic surgeon initiated ECMO, improving her oxygenation and thus stabilizing her for transfer. The patient was received at the referral center, underwent surgical embolectomy, vena caval filter insertion, and anticoagulation. A hematological workup was notable for a Factor V Leiden mutation. The patient did well postoperatively and was discharged home Neurologically intact on chronic anticoagulation.

To our knowledge, this is a novel case not previously reported in emergency medicine literature whereby ECMO was used in the ED for shock because of massive PE. As was noted in this case, with Cardiovascular collapse due to acute PE, ECMO can be an effective and invaluable modality for the patient in extremis [1]. Although emergen- cy physicians will not initiate ECMO themselves, knowing that this possibility exists may offer an option when the patient is refractory to thrombolysis and surgical embolec- tomy is not an immediate option. In addition, the ED bedside ultraSonographic findings of dilated right heart

Fig. 1 Bedside ultrasound showing dilated right ventricle (RV) with prolapsing thrombus and minimally filled Left ventricle .

chambers can be beneficial in the evaluation of the acutely dyspneic patient [2].

Randall Deehring MD Attilla B. Kiss MD Aaron Garrett DO Anthony G. Hillier DO

Department of Emergency Medicine St. John West Shore Hospital Westlake, OH 44145, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2006.03.009

References

1. Gulba DC, Schmid C, Borst HG, Lichtlen P, et al. Medical compared with surgical treatment for massive pulmonary embolism. Lancet 1994;343:576 - 7.
2. Kasper W, Meinertz T, Henkel B, Eissner D, et al. echocardiographic findings in patients with proved pulmonary embolism. Am Heart J 1986;112(6):1284 - 90.

Polymer fume fever after use of a household product

Polytetrafluoroethylene (PTFE or Teflon) is a commonly used compound that may result in polymer fume fever (PFF) when heated in poorly ventilated conditions. Polymer fume

This study was presented as an abstract at European Congress of Clinical Toxicology, Rome Italy, May 2003.

fever in persons smoking contaminated cigarettes is an occupational hazard in industries where these products are used [1]. Cases of PFF in persons exposed to pyrolyzed hairspray and horse-rug waterproofing spray have recently been reported [2,3]. Because of the increasing use of PTFE in commercial and industrial products, recognition of this entity is of importance to emergency medicine and occupational medicine physicians. We report on a case of PFF in a man using a commonly found household product in conjunction with hand-rolled cigarettes.

A previously healthy 40-year-old man developed fever, chills, cough, and progressive dyspnea after using Elmer’s Slide-All dry lubricant for the first time. After extensive hand contact with the micronized PTFE product at Room temperature, he hand rolled and smoked a hash-tobacco joint. He noted that his symptoms began with a vigorous cough after a few tokes. He presented to the ED 8 hours later with coughing and dyspnea at rest. His vital signs were noted as follows: temperature, 39.48C; heart rate, 80; relative risk, 24; and pulse oximetry, 90% on room air. Examinations revealed retractions and expiratory wheezing. A chest radiograph showed bilateral alveolar infiltrates, and his peak flows improved from 200 to 450 L/min with 3 albuterol treatments. pulmonary function tests 16 hours after exposure revealed moderate airway obstruction that was reversed with albuterol. He improved over 48 hours without further therapy and was asymptomatic at 7 days and at 3 months after exposure. The discharge diagnosis was PFF. The MSDS (Material Safety Data Sheets) for this product as of February 2006 did not indicate a risk of PFF in association with use of smoking materials, and this was reported to the manufacturer and to the Occupational Safety and Health Administration.