Letters to the Editor
Paradoxical embolism should be considered in all patients with an arterial embolus in the absence of a cardiac or proximal arterial source. Since its first description by Cohnheim in 1877, the entity of paradoxical embolism through a PFO has remained a diagnostic challenge (1). Definite confirmation of paradoxical embolism essentially requires the detection of a right atrial thrombus crossing the foramen ovale. In patients with major pulmonary embolism, echocardiographic detection of a PFO signifies a particularly high risk of death and arterial thromboembolic complications. Further, such patients might be particularly prone to suffer paradoxical embolism with a substantial impact on their in-hospital morbidity and mortality (2). Percutaneous PFO closure seems to be a promising technique in the prevention of recurrent systemic thromboembolism in patients with a PFO after a first event (3). However, closure of a PFO does not treat venous thromboembolic disease. Closure of a PFO by open or percutaneous methods with inferior vena cava interruption is recommended in patients with presumptive massive pulmonary embolism who have contraindications to systemic anticoagulation. Patients with a PFO and paradoxical embolism are also at increased risk for recurrent thromboembolic events, with a combined cerebrovascular accident and transient ischemic attack rate of 3.4% to 3.8% per year (4,5).
sanne Study. Lausanne Stroke with Paradoxical Embolism Study Group. Neurology 1996;46:1301–5.
, SOSMAT: SINGLE-OPERATOR SCAPULAR MANIPULATION AND TRACTIONCOUNTERTRACTION FOR REDUCTION OF ANTERIOR SHOULDER DISLOCATION , To the Editor: Shoulder dislocation is a common problem in emergency medicine, with about 70,000 presentations per year in the United States (1). A great many techniques for reducing glenohumeral dislocations are available, with the most recently introduced being the gentle and atraumatic FARES (fast, reliable, and safe) method (2). Nonetheless, physicians commonly resort to the brutal method of traction-countertraction, in which the patient is pinioned from behind with a sheet while the operator applies traction to the affected extremity. Procedural sedation with propofol or other agents is used commonly, as is intra-articular lidocaine. A new method of reducing anterior shoulder dislocations is presented here, with a case report. It is called SOSMAT, which is an acronym for “single-operator scapular manipulation and traction-countertraction.” The author developed this technique when faced with an elderly patient with a glenohumeral dislocation. She was not
Cristina Rodrı´guez-Escot, MD Luciano Santana-Cabrera, MD Juan Jose´ Ca´ceres-Agra, MD Manuel Sa´nchez-Palacios, MD Intensive Care Unit University Hospital Insular in Gran Canaria Las Palmas de Gran Canaria, Spain http://dx.doi.org/10.1016/j.jemermed.2012.05.036
REFERENCES 1. Cohnheim J. Thrombose und embolie. Vorlesungen uber allgemeine pathologie, Vol. 1 [German]. Berlin, Germany: Hirschwald; 1877: 134. 2. Konstantinides S, Geibel A, Kasper W, Olschewski M, Blu¨mel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998; 97:1946–51. 3. Windecker S, Wahl A, Chatterjee T, et al. Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: longterm risk of recurrent thromboembolic events. Circulation 2000; 101:893–8. 4. Mas JL, Zuber M, French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. Am Heart J 1995;130: 1083–8. 5. Bogousslavsky J, Garazi S, Jeanrenaud X, Aebischer N, Van Melle G. Stroke recurrence in patients with patent foramen ovale: the Lau-
Figure 1. The cow hitch. A half hitch also works well.
The Journal of Emergency Medicine
Figure 2. Securing the sheet.
a good sedation candidate, and the emergency department was severely overcrowded with multiple unstable patients, so sedation could not be accomplished in a reasonable amount of time. A common practice before reduction of shoulder dislocation is to elevate the bed and affix weights to the extremity to fatigue the musculature that holds the dislocated humerus in place. This led to the idea that prone positioning might allow better mechanical advantage. A 70-year-old woman presented with shoulder pain and decreased range of motion after a mechanical fall. A glenohumeral dislocation was obvious, and there were no other injuries. The patient was given ibuprofen 400 mg, acetaminophen 1000 mg, diazepam 5 mg, and hydromorphone 2 mg, all orally, and was sent for an X-ray. After the film confirmed the diagnosis, the SOSMAT procedure was undertaken. THE SOSMAT PROCEDURE 1. Patient positioned prone, with the affected arm hanging off the gurney. 2. Gurney raised to maximal height. 3. Sheet tied to patient’s wrist, using a cow hitch (Figure 1) or a half hitch.
Figure 3. SOSMAT, single-operator scapular manipulation and traction-counter traction.
4. Operator’s foot placed over the sheet, beside the patient’s wrist, while the sheet is directed toward the ceiling (Figure 2). 5. Proximal end of sheet is fastened to operator’s distal femur simply by winding the sheet to create friction, with knee flexed. Operator stands on one foot, leaning against the patient for balance, with the hands in position to achieve scapular manipulation. 6. Operator is now in a position to utilize scapular manipulation while applying a great deal of traction-countertraction force (Figure 3). The patient’s dislocation was reduced in approximately 5 s, and with minimal discomfort. The reduction was confirmed radiographically, and there was no Hill-Sachs or Bankart lesion. This procedure has been used successfully on approximately 20 patients, including some patients who had failed other methods. In two cases, the procedure was used after other methods failed while the patient was already sedated with propofol; the SOSMAT method was successful in both cases. No other method facilitates simultaneous scapular manipulation and traction-countertraction. Methods of shoulder reduction are almost as numerous as emergency physicians, and each one has its advantages. A
comprehensive review is beyond the scope of this letter. The advantages of the new SOSMAT method include: 1) Only one operator is required; 2) The method uniquely combines scapular manipulation with traction-countertraction. Scapular manipulation brings the glenoid cup out and down to meet the humeral head while tractioncountertraction brings the humeral head from its impacted location beneath the glenoid to a position in line with the glenoid, so that it can be reduced; 3) The positioning, and use of the operator’s leg strength, allows generation of greater traction-countertraction forces than the method that relies on holding the patient back with a sheet; 4) This combination of scapular manipulation and traction-countertraction seems to be so mechanically advantageous that deep sedation or intra-articular lidocaine is not needed; 5) The patient is more comfortable prone on the mattress than she would be pinioned from behind by a sheet, as the mattress provides better padding then a tightly tensioned sheet; 6) This procedure has been successful with minimal sedation, though it also has been used after the administration of deep sedation, when other methods had failed; 7) Finally, the humerus is not subjected to any lateral stress, and this may lessen the chance of secondary injury or displacement of a fracture that was not detected because a pre-reduction radiograph was not done, or because the fracture was non-displaced and was missed on the pre-reduction radiograph. This new method does have some potential weaknesses. First of all, its safety and efficacy will have to be studied in a formal way, with comparison to other methods. Secondly, the operator’s positioning is awkward, and re-
Letters to the Editor
quires that he or she lean on the patient. Finally, some operators may be uncomfortable placing patients prone after administering sedatives; however, monitoring is still possible and a trip to the operating room may be avoided. Daniel J. Pallin, MD Department of Emergency Medicine Brigham and Women’s Hospital Boston, Massachusetts http://dx.doi.org/10.1016/j.jemermed.2012.05.040 REFERENCES 1. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am 2010;92:542–9. 2. Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Reduction of acute anterior dislocations: a prospective randomized study comparing a new technique with the Hippocratic and Kocher methods. J Bone Joint Surg Am 2009;91:2775–82.
, A HUGE AORTIC ROOT PSEUDOANEURYSM , To the Editor: A 53-year-old man presented to the Emergency Department (ED) with a 2-day history of progressive shortness of breath and fever. He had a medical history of hyperthyroidism, congestive heart failure, and valvular heart disease. In addition, he had received valve replacements, including aortic valve, mitral valve, and tricuspid valve 2 months previously due to significantly valvular dysfunction. His initial vital
Figure 1. (A) Supine chest radiograph revealed a right middle lung mass (arrow) and four metallic wires. In addition, cardiomegaly was also noted. (B,C) An axial view and a coronal view of a contrast computed tomography scan showed an 11 9 6 cm3 anterior mediastinal mass with irregular margins and fluid-fluid level (white arrow), which compressed aortic root, left atrium, right atrium, and superior vena cava. Extravasation of the contrast material from the aortic root into the mass was noted (black arrow), indicating aortic pseudoaneurysm. In addition, a moderate right-sided pleural effusion and a metallic aortic valve were found.