Judge Gillian, Bakhshi Waslat, Sands Fiona, Comer Christine, Castle Bryan
Emergency Medicine, Mater Misericordiae University Hospital, Dublin, IRL.
Trauma Inpatient Service, Mater Misericordiae University Hospital, Dublin, IRL.
Cureus. 2024 Nov 16;16(11):e73824. doi: 10.7759/cureus.73824. eCollection 2024 Nov.
A 61-year-old man in critical condition was admitted to the resuscitation room in the emergency department, presenting with chest pain and shortness of breath. His medical history included recent treatment with oral antibiotics for pneumonia, long-standing chronic obstructive pulmonary disease (COPD), a 40-pack-year smoking history, and a left popliteal artery embolus. He was also on chronic medications, including apixaban and aspirin. Initially, the patient did not recall or volunteer a recent history of repeated falls from standing height. An electrocardiogram (ECG) showed sinus tachycardia. A chest radiograph raised suspicion of an increased left-sided effusion, and a subsequent computed tomography pulmonary arteriography (CTPA) confirmed displaced fractures of the left sixth and seventh ribs. A large, expanding mediastinal hematoma measuring 15 cm in depth was also identified. An urgent CT aortogram was performed, revealing ongoing contrast extravasation without major vessel injury. The hematoma exerted a mass effect on the adjacent right ventricle, although no significant pericardial effusion or fluid was detected. The anticoagulant effect of apixaban was rapidly reversed following specialized hematological advice, using andexanet alpha. This intervention's potential risks and benefits were carefully considered, particularly regarding heparin unresponsiveness and the complications that might arise if bypass surgery became necessary. The patient then underwent an emergency sternotomy, during which a large anterior mediastinal hematoma was successfully evacuated without complications. He ultimately made a full recovery. Falls from less than 2 meters in height are becoming an increasing public health concern at a population level. In older patients, there should be a lower threshold for considering cross-sectional imaging. Many patients in this demographic are on direct oral anticoagulants, so it is crucial to consider and discuss the reversal of these agents with relevant multidisciplinary teams. This case highlights the complexities of polypharmacy and the medical challenges posed by the reversal agent andexanet alpha. Expanding mediastinal hematomas causing obstructive shock are rare, with most literature describing posterior rather than anterior mediastinal hematomas, particularly in cases resulting from a simple fall.
一名61岁的重症男子被送往急诊科复苏室，伴有胸痛和呼吸急促。他的病史包括近期因肺炎接受口服抗生素治疗、长期慢性阻塞性肺疾病（COPD）、40年的吸烟史以及左腘动脉栓塞。他还在服用包括阿哌沙班和阿司匹林在内的慢性药物。最初，患者没有回忆起或主动提及近期有从站立高度反复跌倒的病史。心电图（ECG）显示窦性心动过速。胸部X光片怀疑左侧胸腔积液增加，随后的计算机断层扫描肺动脉造影（CTPA）证实左侧第六和第七肋骨移位骨折。还发现了一个深度为15厘米的巨大、不断扩大的纵隔血肿。进行了紧急CT主动脉造影，显示有持续的造影剂外渗，但没有大血管损伤。血肿对相邻的右心室产生了占位效应，尽管未检测到明显的心包积液或液体。根据专业血液学建议，使用andexanet alpha迅速逆转了阿哌沙班的抗凝作用。仔细考虑了该干预措施的潜在风险和益处，特别是关于肝素无反应性以及如果需要进行搭桥手术可能出现的并发症。然后患者接受了紧急胸骨切开术，在此过程中成功清除了一个巨大的心前区纵隔血肿，没有出现并发症。他最终完全康复。从不到2米的高度跌落正日益成为一个在人群层面上受到关注的公共卫生问题。在老年患者中，应降低考虑进行横断面成像的阈值。这一人群中的许多患者正在服用直接口服抗凝剂，因此与相关多学科团队考虑并讨论这些药物的逆转至关重要。本病例突出了多重用药的复杂性以及逆转剂andexanet alpha带来的医学挑战。导致梗阻性休克的扩大纵隔血肿很少见，大多数文献描述的是后纵隔血肿而非前纵隔血肿，尤其是在因简单跌倒导致的病例中。
