592 Correspondence

Bentley MA, Crawford JM, Wilkins JR, Fernandez AR, Studnek JR. An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care 2013;17:330-8.

Studnek JR, Crawford JM, Wilkins III JR, Pennell ML. Back problems among emergency medical services professionals: the LEADS health and wellness follow- up study. Am J Ind Med 2010;53:12-22.

Myers JB, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, et al. Evidence- based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care 2008;12:141-51.

Antibody-mediated ADAMTS13 deficiency workup is commonly missed?^,??

To the Editor,

We thank Strobel et al [1] for their interesting case study, “A case of thrombotic thrombocytopenic purpura presenting as refractory hypo- glycemia in a patient with Thromboangiitis obliterans” published in The American Journal of Emergency Medicine.

The authors reported a 39-year-old woman with thrombotic throm- bocytopenic purpura presenting with Refractory hypoglycemia. The pa- tient was admitted to the intensive care unit and unfortunately developed cardiac arrest with unsuccessful resuscitation. We wonder if workup for ADAMTS13 deficiency was performed. In the case of severe ADAMTS13 deficiency, early identification of an antibody-mediated ADAMTS13 deficiency may allow targeted therapies such as B lympho- cyte-depleting monoclonal antibodies [2]. In addition, monoclonal protein-related thrombotic microangiopathy was reported [3]. Howev- er, we agreed that this was a difficult and severe condition, and we respected the final decision of resuscitation withdrawals.

The author Replies:

We thank the reader for his interest in this unfortunate case of a middle-aged woman with thromboangiitis obliterans developing thrombotic thrombocytopenic purpura presenting as severe refractory hypoglycemia. We appreciate the importance of sending for ADAMTS13 deficiency early in the workup, even in an unstable patient. Based on your recommendations, treatment varies and can be targeted based on genetic profile for patients who survive until the results analysis is com- pleted. The results of the ADAMTS13 were less than 10% in our patient.

Ashley M. Strobel, MD

Charat Thongprayoon, MD

Department of Internal Medicine, Mayo Clinic, Rochester, MN

Vareena Laohaphan, MD

Department of Emergency Medicine, Phramongkutklao College of Medicine

Bangkok, Thailand

Narat Srivali, MD

Department of Pulmonary and Critical Care Medicine, Mayo Clinic

Rochester, MN Corresponding author at: Mayo Clinic, Rochester, MN 55905

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.022

References

1. Strobel A, Gingold DB, Calvello EJ. A case of thrombotic thrombocytopenic purpura presenting as refractory hypoglycemia in a patient with thromboangiitis obliterans. Am J Emerg Med 32(12):1554 e5-7.
2. Coppo P, Schwarzinger M, Buffet M, Wynckel A, Clabault K, Presne C, et al. Predictive fea- tures of severe acquired ADAMTS13 deficiency in idiopathic thrombotic microangiopa- thies: the French TMA reference center experience. PLoS One 2010;5:e10208.

   ? Conflicts of interest: The authors disclose no conflicts.

   ?? Authors’ contributions: All authors were involved and approved the final manuscript.

   Cheungpasitporn W, Leung N, Sethi S, Gertz MA, Fervenza FC. Refractory atypical he- molytic uremic syndrome with monoclonal gammopathy responsive to bortezomib- based therapy. Clin Nephrol 2014 [Epub ahead of print].

   Importance of tube position after tube thoracostomy

   

   To the Editor,

   We read the article of Matsumoto et al [1] with great interest. We thank them for the topic that is generally overlooked.

   Tube thoracostomy can be a lifesaving procedure especially in traumas. It is applied for the treatment of pneumothorax and hemotho- rax. Tube thoracostomy is performed blindly. Adhesions, collapse ratio of the lung, the incision site, and the guidance of the tube by the practition- er determine the tube position. Sometimes, in a trauma patient, there is a limited time and limited patient positioning for tube thoracostomy. Be- cause of these reasons, a posterosuperiorly guided tube may be at the hilum, above the diaphragm, or even at the anterior paracardiac area. In a trauma patient, we think that evacuation of the blood is much more important than pneumothorax - excluding tension pneumotho- rax - that can be managed with a large bore needle before the tube thoracostomy. The amount of blood drained determines whether to per- form thoracotomy. If the tube is not positioned posteriorly, the drainage may be deceiving. This misread of the drainage may lead to a delayed thoracotomy that can later result with mortality. In addition, inadequate- ly drained hemothorax may lead to pleural thickening or empyema [2]. We think that if persistent expansion defect after a tube thoracostomy is seen, it can be evacuated by simple aspiration or with a small 7-F catheter from second intercostal space on the midclavicular line instead of tube thoracostomy [3]. We again thank the authors of the

   article for pointing out the topic.

   Sezai Cubuk, MD?

   Gata Medical Faculty, Department of Thoracic Surgery, Ankara, Turkey

   * Corresponding author. Tel.: +90 5424868489; fax: +90 3123533702

   E-mail: [email protected]

   Orhan Yucel

   Gata Haydarpasa Teaching Hospital Department of Thoracic Surgery, Istanbul, Turkey

   http://dx.doi.org/10.1016/j.ajem.2015.01.027

   References

   Matsumoto S, Sekine K, Funabiki T, Yamazaki M, Orita T, Shimizu M, et al. chest tube insertion direction: is it always necessary to insert a chest tube posteriorly in primary trauma care? Am J Emerg Med 2015;33(1):88-91. http://dx.doi.org/10.1016/j.ajem. 2014.10.042.

3. Cangir AK, Yuksel C, Dakak M, Ozgencil E, Genc O, Akay H. Use of intrapleural strep- tokinase in experimental minimal clotted hemothorax. Eur J Cardiothorac Surg 2005;27(4):667-70.
4. Choi WI. Pneumothorax. Tuberc Respir Dis (Seoul) 2014;76(3):99-104. http://dx.doi. org/10.4046/trd.2014.76.3.99.

   Screening for and prophylaxis of venous thromboembolism in severe carbon monoxide poisoning?

   

   Carbon monoxide (CO) is a colorless, tasteless, odorless, and nonirritating gas formed when carbon in fuel is not burned completely. It enters the bloodstream through the lungs and attaches to hemoglobin (Hb) forming carboxyhemoglobin (CO-Hb). High CO-Hb combination is poisonous [1-3]. Indeed, during CO poisoning, oxygen delivery