The patient was a 58-year-old male with histories of rheumatoid arthritis, chronic atrial fibrillation, hypertension, diabetes, dyslipidemia, and atrophic gastritis. He had been orally administered four 2-mg capsules of methotrexate once a week, one 5-mg tablet of folic acid once a week, one 15-mg tablet of rivaroxaban once a day, one 2.5-mg tablet of bisoprolol fumarate once a day, one 1-mg tablet of pitavastatin Ca once a day, two 500-mg tablet of metformin twice a day, three 60-mg tablet of loxoprofen Na 3 times a day, and one 15-mg tablet of lansoprazole OD once a day.
He suddenly fainted in the presence of colleagues and promptly received bystander CPR by colleagues. The ambulance crew arrived after 10 minutes and performed direct cardioversion (DC) once after checking the VF waveform. Return of spontaneous circulation (ROSC) was achieved soon, and the patient was transported to the hospital that first treated him. At the time of arrival, ECG showed atrial fibrillation, ST elevation in aVR, and diffuse ST depression in V1-6, suggesting cardiopulmonary arrest due to ST-elevation myocardial infarction (STEMI), and the patient was transferred to our hospital.
At the time of the arrival at our hospital, the patient had tracheal intubation and showed a heart rate of 124 bpm, blood pressure of 148/79, 100% arterial blood oxygen saturation by 10 L oxygen administration, body temperature of 36.5°C, and a state of consciousness of GCS E1V1M4 under midazolam sedation. Bayaspirin and Efient were administered, and coronary angiography (CAG) was promptly performed. The results showed that 99% of stenoses were observed in #6–7 and #9, and, with a diagnosis of STEMI, percutaneous catheter intervention (PCI) and stenting were performed. Intravenous administration of heparin was initiated during PCI. Also, while computed tomography (CT) performed at the time of arrival showed bilateral pleural effusion and atelectasis on the dorsal side, no rib fracture or clear intrapleural hematoma formation was noted.
The patient was thereafter managed in the ICU. Induced hypothermia with a target temperature of 34°C was performed for 24 hours, followed by rewarming over 24 hours. As for anticoagulant therapy, ACT was controlled at ≥ 250 seconds by intravenous administration of heparin Na, and the administration of Aspirin and Plasgrel hydrochloride was continued. The patient was extubated on the 7th hospital day as the extubation criteria were met. No bleeding into the airway was noted during the course.
Heparin administration was ended on the 8th hospital day and was switched to one 15-mg tablet of rivaroxaban once a day. On the same day, radiolucency was found to be reduced in the right middle and lower lung fields on chest radiography, and pneumonia and pleural effusion were suspected (Fig. 1). Although antibiotics and diuretics were used for the treatment, the response of the respiratory condition was poor with a P/F = 250. Therefore, to examine the status of pneumonia and pleural effusion, CT was performed on the 9th hospital day, disclosing the presence of intrapulmonary hematoma on the dorsal side of the right lower lobe (Fig. 2).
Since little improvement was observed also on the 10th hospital day, CT-guided puncture and drainage of the hematoma in the right lower lobe were attempted. Although the guide wire could be inserted, insertion of the pig-tail catheter was difficult, and drainage could not be achieved. This procedure induced pneumothorax, and the fluid discharged into the thoracic cavity was yellowish and serous, indicating that the lesion was intrapulmonary hematoma. Since CT-guided drainage was difficult, surgical treatment was selected, and surgery was scheduled on the 13th hospital day.
Open chest evacuation of hematoma in the lower lobe of the right lung was performed. Thoracotomy was made at the right 5th intercostal space. Thoracoscopy showed visceral subpleural hematoma on the dorsal side of S6-10 of the right lung. The visceral pleural was incised, and 50 g of hematoma was resected (Fig. 3). To the area where slight air leakage and oozing were observed, TachoSil Tissue Sealing sheet® was applied, and Polyglycoal acid (PGA) sheet (5×10 cm) was attached for additional strength. Surgery was ended by placing 24Fr double-lumen thoracic drains on the diaphragm and on the dorsal aspect of the lung. The operative time was 125 minutes, and the volume of hemorrhage was 200 mL. On postoperative radiography, radiolucency of the right lower lung field was markedly improved compared with the preoperative images (Fig. 3).
Although the respiratory condition showed temporary exacerbation after surgery, it improved gradually, and the drain on the dorsal side was removed on the 16th hospital day. The respiratory condition was improved to P/F > 350 on the 19th hospital day, and the patient was discharged from the ICU. The second drain was removed on the 20th hospital day. Thereafter, cardiac rehabilitation was implemented, and the patient was discharged to home with no disabilities on the 26th hospital day.