Serum C-reactive protein value on day 14 as a possible prognostic factor of aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Serum C-reactive protein (CRP), as a reflection of early brain injury at onset, is a prognostic factor in aneurysmal subarachnoid hemorrhage (aSAH). However, in some severe cases, patients exhibit a good prognosis despite their elevated serum CRP level. Therefore, we examined the relationship between serum CRP transitions in the acute phase of aSAH and the prognosis. METHODS: We recruited 63 patients with aSAH and retrospectively analyzed the relationships between the serum CRP transitions during the acute phase and the prognosis, patient background, and clinical course. RESULTS: Serum CRP values on days 1, 3, and 14 were significantly lower in the good prognosis group than those in the poor prognosis group. Moreover, serum CRP values on days 1 and 14 significantly affected the prognosis in the multiple regression analysis. CONCLUSIONS: A low serum CRP value on day 14, in addition to that on day 1 as reported previously, is associated with a good prognosis of aSAH. Furthermore, a good prognosis of aSAH is determined not only by absence of early brain injury at onset but also by appropriate management to obtain a low serum CRP value on day 14.

Clinical Features and Treatment of Patients Infected With SARS-CoV-2 Omicron Variant While Hospitalized Due to Stroke: A Single Center Study in Japan.

BACKGROUND AND OBJECTIVE: In December 2019, COVID-19 spread rapidly across the globe. Throughout the pandemic, SARS-CoV-2 repeatedly mutated, transitioning from the alpha variant to the omicron variant. The severity and mortality of COVID-19 have been linked to age, sex, and the presence of underlying diseases (respiratory, cerebrovascular, cardiovascular, metabolic, and immune diseases, as well as cancer). The clinical features of patients infected with COVID-19 following a stroke, however, are fully unknown. Therefore, it is significant to explore the appropriate treatment for these patients based on their clinical features. METHODS: Of the 6175 patients who visited Asahi Hospital (Tokyo, Japan) between November 2022 and February 2023, 206 were admitted. Of these 206 patients, the 44 that contracted COVID-19 while hospitalized for strokes were retrospectively analyzed. RESULTS: Six (13.6%) of these patients died; four expired due to coagulopathy associated with ischemic heart failure and recurrent ischemic cerebrovascular disease. The mean D-dimer level increased to 3.53 in the deceased patients, while it was 1.64 in all patients. The platelet count was low in three of the deceased patients, while it was high in two patients. The severity of COVID-19 was significantly correlated with a high modified Rankin Scale (mRS) score and a high National Institute of Health Stroke Scale (NIHSS) score. The timing of vaccination is inversely correlated with COVID-19 severity. CONCLUSION: Patients with COVID-19 after a stroke have high mortality rates due to coagulopathy. Stroke patients with high mRS scores and high NIHSS scores are more likely to develop severe COVID-19. Anticoagulant therapy should be administered to COVID-19 patients with high mRS scores following a stroke.

Stroke classification and treatment support system artificial intelligence for usefulness of stroke diagnosis.

Background and aims: It is important to diagnose cerebral infarction at an early stage and select an appropriate treatment method. The number of stroke-trained physicians is unevenly distributed; thus, a shortage of specialists is a major problem in some regions. In this retrospective design study, we tested whether an artificial intelligence (AI) we built using computer-aided detection/diagnosis may help medical physicians to classify stroke for the appropriate treatment. Methods: To build the Stroke Classification and Treatment Support System AI, the clinical data of 231 hospitalized patients with ischemic stroke from January 2016 to December 2017 were used for training the AI. To verify the diagnostic accuracy, 151 patients who were admitted for stroke between January 2018 and December 2018 were also enrolled. Results: By utilizing multimodal data, such as DWI and ADC map images, as well as patient examination data, we were able to construct an AI that can explain the analysis results with a small amount of training data. Furthermore, the AI was able to classify with high accuracy (Cohort 1, evaluation data 88.7%; Cohort 2, validation data 86.1%). Conclusion: In recent years, the treatment options for cerebral infarction have increased in number and complexity, making it even more important to provide appropriate treatment according to the initial diagnosis. This system could be used for initial treatment to automatically diagnose and classify strokes in hospitals where stroke-trained physicians are not available and improve the prognosis of cerebral infarction.

International cooperation for nursing human resource development in Lao PDR: Investing in nursing leadership.

Strengthening nursing leadership in health systems has been identified as a priority for achieving Universal Health Coverage (UHC). We aimed to analyse the characteristics of Japanese technical assistance projects for nursing human resource development in Lao People's Democratic Republic (Lao PDR) and suggest directions for future assistance. An upgrading program, as part of human resource development, was initiated in the 1990s; it has contributed to the development of nursing leaders. Moreover, technical assistance from development partners has had synergistic effects by consistently promoting the involvement of nursing leaders in administration, education, and clinical practice to establish a functional regulatory system. In resource-limited settings, the application of both edge-pulling (leadership development) and bottom-up (quality improvement of the mass population) strategies are required. From a long-term perspective, development partners should continue to invest in increasing the number and quality of nursing leaders by upgrading the courses and leadership training programs, starting from the younger generation.

Preoperative Rehearsal Sketch for Cerebral Aneurysm Clipping Improves the Accuracy and the Safety of the Surgical Procedure.

OBJECTIVE: With advances in endovascular therapy, the number of cerebral aneurysm clippings has been decreasing. However, some patients are indicated for clipping surgeries. In such circumstances, preoperative simulation is important for the safety and educational aspects of the operation. Herein, we introduce a simulation method using the preoperative rehearsal sketch and report its applicability. METHODS: We compared the preoperative rehearsal sketch with the surgical view for all patients who underwent cerebral aneurysm clipping by neurosurgeons below the seventh grade between April 2019 and September 2022 in our facility. The aneurysm, running of parent and branched arteries, perforators, veins, and clip working were evaluated by senior doctors and scored as follows: correct, 2; partially correct, 1; incorrect, 0; and total score, 12. We retrospectively evaluated the relationship between these scores and postoperative perforator infarctions and, in addition, compared that between simulated and not simulated cases. RESULTS: In the simulated cases, the total scores did not correlate with perforator infarctions, but assessments of the aneurysm, perforators, and clip working affected the total score (P = 0.039, 0.014, and 0.049, respectively). Moreover, perforator infarctions were significantly less in the simulated cases (6.3% vs. 38.5%; P = 0.03). CONCLUSIONS: Precise interpretations of preoperative images and considerations of three-dimensional images are imperative to perform safe and accurate surgeries using preoperative simulation. Although perforators are not always detected preoperatively, it is possible to presume in the surgical view using anatomic knowledge. Therefore, drawing the preoperative rehearsal sketch improves the safety of surgical procedure.

Swallowability of Minitablets among Children Aged 6-23 Months: An Exploratory, Randomized Crossover Study.

Minitablets have garnered interest as a new paediatric formulation that is easier to swallow than liquid formulations. In Japan, besides the latter, fine granules are frequently used for children. We examined the swallowability of multiple drug-free minitablets and compared it with that of fine granules and liquid formulations in 40 children of two age groups (n = 20 each, aged 6-11 and 12-23 months). We compared the percentage of children who could swallow minitablets without chewing with that of children who could swallow fine granules or liquid formulations without leftover. The children who visited the paediatric department of Showa University Hospital were enrolled. Their caregivers were allowed to choose the administration method. In total, 37 out of 40 caregivers dispersed the fine granules in water. Significantly more children (80%, 95% CI: 56-94%) aged 6-11 months could swallow the minitablets than those who could swallow all the dispersed fine granules and liquid formulations (22%, 95% CI: 6-47% and 35%, 95% CI: 15-59%, respectively). No significant differences were observed in children aged 12-23 months. Hence, minitablets may be easier to swallow than dispersed fine granules and liquid formulations in children aged 6-11 months.

Cardiac Arrest in a 33-year-old Marathon Runner with Anomalous Right Coronary Artery Originating from the Pulmonary Artery.

A 33-year-old marathon runner presented with anomalous right coronary artery originating from the pulmonary artery after being admitted for cardiac arrest. Surgical re-implantation of the right coronary artery to the aortic root to re-establish right coronary ostial circulation was successful. The patient resumed exercise and required no further medical therapy.

Assessing the feasibility of introducing an electronic health information system into Tuberculosis clinics and laboratories in Myanmar.

Myanmar has launched an advanced tuberculosis examination policy, which involves specimen exchanges among clinics and referral laboratories. However, with the current paper-based operation, it is difficult to trace information accurately. Therefore, since April 2017, we introduced a pilot operation consisting of an electronic health information system (HIS) that uses QR codes for data sharing in the tuberculosis laboratory at seven facilities. This study aimed to assess the feasibility of introducing the electronic HIS into tuberculosis clinics and laboratories based on staff perception, workload and workflow, and data accuracy, and to clarify its advantages and disadvantages. The analysis was descriptive, and it involved a semi-structured interview for the staff, workflow observations to evaluate the workload and describe the change in workflow, and evaluation of the data accuracy by comparing the numbers yielded by the paper-based and HIS-based reports. The HIS was positively accepted as it improved work efficiency, while the operation still depended on paper-based reports. Parallel data registration using both paper-based and HIS-based reports increased the workload. Data discrepancies were found when comparing the paper-based and HIS-based reports, and these discrepancies were not directly attributed to the HIS introduction but individual factors. Crucial facilitating factors of the HIS were its operability and user-friendliness, because it does not require specific training. The additional workload translates into the need for additional human resources, and the parallel data registration remains a challenge. However, we consider that these challenges could be overcome as coverage of the HIS expands.

A Successful Treatment Strategy for Paradoxical Cerebral Embolism Accompanied by Entrapped Thrombus in Patent Foramen Ovale.

A 73-year-old man was transferred to our hospital with dyspnea and left hemiplegia. The diagnosis of pulmonary embolism, entrapped thrombus in patent foramen ovale (PFO), and internal carotid artery occlusion was made by imaging studies. We decided to perform endovascular treatment without the administration of tissue plasminogen activator (tPA) for cerebral embolism because of concern about further embolism caused by fragmented thrombi. After endovascular treatment, he successfully underwent surgical embolectomy for entrapped thrombus in PFO. Endovascular treatment without tPA administration and subsequent surgical embolectomy seems to be a viable treatment strategy for patients with occlusion of the large cerebral artery accompanied by entrapped thrombus in PFO.

Left ventricular wall findings in non-electrocardiography-gated contrast-enhanced computed tomography after extracorporeal cardiopulmonary resuscitation.

BACKGROUND: Few studies have reported left ventricular wall findings in contrast-enhanced computed tomography (CE-CT) after extracorporeal cardiopulmonary resuscitation (ECPR). This study examined left ventricular wall CE-CT findings after ECPR and evaluated the association between these findings and the results of coronary angiography and prognosis. METHODS: We evaluated out-of-hospital cardiac arrest patients who were treated with ECPR and subsequently underwent both non-electrocardiography-gated CE-CT and coronary angiography at our center between January 2011 and April 2018. Left ventricular wall CE-CT findings were classified as follows: (1) homogeneously enhanced (HE; the left ventricular wall was homogeneously enhanced), (2) segmental defect (SD; the left ventricular wall was not segmentally enhanced according to the coronary artery territory), (3) total defect (TD; the entire left ventricular wall was not enhanced), and (4) others. Successful weaning from extracorporeal membrane oxygenation, survival to hospital discharge, and predictive ability of significant stenosis on coronary angiography were compared among patients with HE, SD, and TD patterns. RESULTS: A total of 74 patients (median age, 59 years) were eligible, 50 (68%) of whom had initial shockable rhythm. Twenty-three (31%) patients survived to hospital discharge. HE, SD, TD, and other patterns were observed in 19, 33, 11, and 11 patients, respectively. The rates of successful weaning from extracorporeal membrane oxygenation (84% vs. 39% vs. 9%, p < 0.01) and survival to hospital discharge (47% vs. 27% vs. 0%, p = 0.02) were significantly different among patients with HE, SD, and TD patterns. In post hoc analysis, patients with HE patterns had a significantly higher success rate of weaning from extracorporeal membrane oxygenation than those with SD and TD patterns. SD predicted significant stenosis with a sensitivity of 74% and specificity of 94%. CONCLUSIONS: Homogenously enhanced left ventricular wall might be a predictor of good left ventricular function recovery. In contrast, total enhancement defect in the entire left ventricular wall was associated with poor outcomes. Contrast defect matching the coronary artery territory could predict significant coronary artery stenosis with good specificity. The left ventricular wall findings in non-electrocardiography-gated CE-CT after ECPR might be useful for diagnosis and prognostic prediction.

Successful support by veno-arterial extracorporeal membrane oxygenation for severe septic shock caused by Aeromonas hydrophila.

BACKGROUND: Septic shock is a subset of sepsis accompanied by profound circulatory and cellular metabolism abnormalities. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary cardiac support to improve organ perfusion, hemodynamic support by VA-ECMO for adult patients with septic shock is still controversial. CASE PRESENTATION: A 67-year-old man was transferred to our hospital with generalized weakness. He suffered septic shock refractory to vasopressors and inotropes, and his cardiac function deteriorated rapidly. Because of concern for sudden cardiac arrest, he was placed on VA-ECMO 9 h after his arrival. Blood culture was positive for Aeromonas hydrophila. He was weaned off VA-ECMO on day 7 and was discharged without any sequelae on day 30. CONCLUSION: Veno-arterial extracorporeal membrane oxygenation is a viable treatment option for adult patients with refractory septic shock accompanied by cardiac dysfunction. Further research is warranted to identify the candidates for support by VA-ECMO in a timely fashion.

Extracorporeal CPR for massive pulmonary embolism in a "hybrid 2136 emergency department".

AIM: Patients with massive pulmonary embolism (PE) have poor outcomes and their management remains challenging. An interventional radiology (IVR)-computed tomography (CT) system available in our emergency room (ER) allows immediate access to CT and extracorporeal membrane oxygenation (ECMO) with safe cannulation under fluoroscopy. We aimed to determine if initial treatment in this "hybrid ER" is helpful in patients with PE requiring extracorporeal cardiopulmonary resuscitation (ECPR). METHODS: The records of patients transferred to our hybrid ER between September 2014 and December 2017 who required ECPR for PE were reviewed. RESULTS: Nine consecutive patients (median age 50 [range 30-76] years) with PE requiring ECPR were identified in our hybrid ER. Five (55.6%) had at least one risk factor for PE. Six (66.7%) experienced an out-of-hospital cardiac arrest and 3 (33.3%) had a cardiac arrest in the hybrid ER. Right ventricular overload was detected on electrocardiography and bedside transthoracic echocardiography in all cases. The median pH, lactate, PaCO2, and HCO3 values on arterial blood gas analysis in the hybrid ER were 7.01 (6.68-7.26), 14 (8-22) mmol l-1, 44.7 (23.8-60.5) mmHg, and 10.4 (6.7-14.1), respectively. Four patients (44.4%) received monteplase for thrombolysis. No patient underwent surgical embolectomy. The median duration of ECMO was 69 (38-126) h. There were two ECMO-related bleeding complications. Eight patients (88.9%) survived and one died of post-resuscitation encephalopathy after weaning from ECMO. CONCLUSION: A hybrid ER may be useful for initial management of massive PE requiring ECPR and may help to improve outcomes.

Etiology of out-of-hospital cardiac arrest in psychiatric patients: Chart review.

AIM: Although sudden cardiac deaths are more common in psychiatric patients than the general population, data on their causes are very limited. The aim of this study was to investigate initial rhythms and causes of out-of-hospital cardiac arrest (OHCA) in patients with psychiatric disorders. METHODS: We conducted a systematic chart review of patients resuscitated after OHCA and hospitalized in the Tertiary Emergency Medical Center of Tokyo Metropolitan Bokutoh Hospital in Japan between January 2010 and December 2017. The initial rhythms and causes of OHCA were compared between psychiatric patients and non-psychiatric patients. Parameters of interest were compared using chi-squared test, Fisher's exact test, or the Mann-Whitney U-test, as appropriate. RESULTS: A total of 49 psychiatric and 600 non-psychiatric patients were eligible for this study. Fatal but shockable arrhythmias (i.e. ventricular fibrillation and ventricular tachycardia) were less frequently observed as initial rhythms in patients with psychiatric disorders than the others (22.4% vs 49.7%, P < 0.001). Cardiac origin was less common as the cause of OHCA (26.5% vs 58.5%, P < 0.01), while airway obstruction and pulmonary embolism were more frequent in psychiatric versus non-psychiatric patients (24.5% vs 6.5%, P < 0.01; and 12.2% vs 1.5%, P < 0.01, respectively). The results were similar when psychiatric patients were compared with sex- and age-matched controls selected from the non-psychiatric patient group. CONCLUSION: Although fatal arrhythmias may be less common, non-cardiac causes such as pulmonary embolism and airway obstruction need to be treated with high clinical suspicion in an event of sudden cardiac arrest in psychiatric patients.

Categorization of post-cardiac arrest patients according to the pattern of amplitude-integrated electroencephalography after return of spontaneous circulation.

BACKGROUND: Continuous electroencephalography (cEEG), interpreted by an experienced neurologist, has been reported to be useful in predicting neurological outcome in adult patients post cardiac arrest. Amplitude-integrated electroencephalography (aEEG) is a type of quantitative EEG and is easily interpreted by a non-neurologist. A few studies have shown the effectiveness of aEEG in prognostication among adult patients post cardiac arrest. In this study, we hypothesized that the pattern of aEEG after return of spontaneous circulation (ROSC) could successfully categorize patients post cardiac arrest according to their expected neurological outcome. METHODS: We assessed the comatose survivors of out-of-hospital cardiac arrest who received targeted temperature management with midazolam-based sedation and were monitored with aEEG at our tertiary emergency care center from January 2013 to June 2017. We categorized the patients into categories 1 (C1) to 4 (C4). C1 included patients who regained continuous normal voltage (CNV) within 12 h post ROSC, C2 included those who recovered CNV 12-36 h post ROSC, C3 included those who did not recover CNV before 36 h post ROSC, and C4 included those who had burst suppression at any time post ROSC. We evaluated the outcomes of neurological function for each category at hospital discharge. A good outcome was defined as a cerebral performance category of 1 or 2. RESULTS: A total of 61 patients were assessed (median age, 60 years), among whom 42 (70%) had an initial shockable rhythm, and 52 (85%) had cardiac etiology. Of all 61 patients, 40 (66%) survived to hospital discharge and 27 (44%) had a good neurological outcome. Of 20 patients in C1, 19 (95%) had a good outcome, while the percentage dropped to 57% among C2 patients. No patients in C3 or C4 had a good outcome. Three patients could not be classified into any category. CONCLUSIONS: The pattern of aEEG during the early post-cardiac-arrest period can successfully categorize patients according to their neurological prognoses and could be used as a potential guide to customize post-cardiac-arrest care for each patient.

Conventional cardiopulmonary resuscitation-induced refractory cardiac arrest due to latent left ventricular outflow tract obstruction due to a sigmoid septum: a case report.

BACKGROUND: Patients with left ventricular outflow tract obstruction who do not exhibit a dynamic pressure gradient at rest, experience pressure gradient increases of ≥ 30 mmHg only during specific situations; this is called latent left ventricular outflow tract obstruction. It is provoked by increased cardiac contraction and preload and afterload depletion. There are a few reports of patients with it developing cardiac arrest. We present a case of latent left ventricular outflow tract obstruction in which the patient with a sigmoid septum experienced refractory pulseless electrical activity due to conventional advanced cardiac life support. CASE PRESENTATION: A 73-year-old Asian woman on escitalopram and lorazepam was transported to our hospital for chest and back pain with altered consciousness. On arrival, she was in shock and developed pulseless electrical activity. After initiation of conventional cardiopulmonary resuscitation according to adult advanced cardiovascular life support guidelines, she could not regain spontaneous circulation. She was ultimately resuscitated via venoarterial extracorporeal membrane oxygenation initiation. The only abnormal laboratory result at admission was anemia. Her hemodynamic status stabilized after red blood cell transfusion, and venoarterial extracorporeal membrane oxygenation was subsequently terminated. Transthoracic echocardiography showed a sigmoid septum; dobutamine-infused Doppler echocardiography revealed a significant outflow gradient, and continuous monitoring showed Brockenbrough-Braunwald sign, which confirmed a diagnosis of latent left ventricular outflow tract obstruction due to a sigmoid septum. As a result, carvedilol and verapamil were initiated. A follow-up dobutamine-infused Doppler echocardiography showed a reduction of outflow gradient, and she was discharged without any sequelae. Latent left ventricular outflow tract obstruction worsened due to increasing cardiac contraction and the depletion of preload and afterload. Depleted preload occurred due to dehydration and anemia, whereas depleted afterload occurred due to the prescribed drugs, which subsequently caused pulseless electrical activity. Moreover, ß-stimulation from the adrenaline probably enhanced the hypercontractile state and caused refractory pulseless electrical activity in our case. CONCLUSIONS: Patients with latent left ventricular outflow tract obstruction can progress to cardiogenic shock and pulseless electrical activity due to increased cardiac contraction and depletion of preload and afterload. We should consider the patient's underlying conditions that induced pulseless electrical activity.

Treatment of a patient with acute aortic dissection using extracorporeal cardiopulmonary resuscitation after an out-of-hospital cardiac arrest: a case report.

Case: Circulatory support using veno-arterial extracorporeal membrane oxygenation for aortic disease is conventionally contraindicated. In this case, a 66-year-old man experienced cardiopulmonary arrest caused by acute aortic dissection. When exercising in the gym, he experienced chest discomfort, so the staff immediately called an ambulance. While in the ambulance, he experienced cardiopulmonary arrest. His initial electrocardiogram showed ventricular fibrillation. At the emergency department, we immediately performed extracorporeal cardiopulmonary resuscitation. We suspected acute coronary syndrome, so coronary angiography was carried out. Enlargement of ascending aorta was noted. Whole-body enhanced computed tomography was subsequently performed, leading to a final diagnosis of acute aortic dissection. Outcome: Emergency ascending aorta prosthesis implantation was performed. The patient received intensive care and was discharged on day 49 of hospitalization. His cerebral performance category score was 4 at discharge. Conclusion: This case suggests that veno-arterial extracorporeal membrane oxygenation may be used for patients with aortic dissection presenting with cardiac arrest.

A case of circumferential type A aortic dissection with intimal intussusception diagnosed using repeat transthoracic echocardiography examination.

Case: Sometimes it is difficult to diagnose circumferential aortic dissection with enhanced computed tomography alone. A 58-year-old woman presented with sudden-onset chest discomfort and loss of consciousness. Transthoracic echocardiogram showed mild aortic regurgitation. Enhanced computed tomography scans showed no obvious intimal tear or flap at the proximal ascending aorta, but an intimal flap was observed from the aortic arch to both common iliac arteries. Stanford type B dissection was tentatively diagnosed. Repeat detailed transthoracic echocardiography examination showed an intimal tear and flap at the ascending aorta; prolapse into the left ventricle caused severe aortic regurgitation. Type A aortic dissection was definitively diagnosed; emergent operation showed a circumferential intimal tear originating from the ascending aorta. Outcome: The ascending aorta was replaced; aortic regurgitation disappeared. The patient was discharged in a good condition 58 days postoperatively. Conclusion: Dynamic evaluations with transthoracic echocardiography should be carried out to diagnose circumferential aortic dissection.

Chest compression-related fatal internal mammary artery injuries manifesting after venoarterial extracorporeal membrane oxygenation: a case series.

BACKGROUND: Cardiopulmonary resuscitation-related bleeding, especially internal mammary artery injuries, can become life-threatening complications after initiating venoarterial extracorporeal membrane oxygenation owing to the frequent involvement of concomitant anticoagulant treatment, antiplatelet treatment, targeted temperature management, and bleeding coagulopathy. We report the cases of five patients who experienced this complication and discuss their management. CASE PRESENTATION: We retrospectively evaluated five patients with cardiopulmonary resuscitation-related internal mammary artery injuries who were treated between February 2011 and February 2016 at our institution. All five patients were Asian men, aged 56 to 68-years old, who had received concomitant intravenously administered unfractionated heparin (3000 units) with antiplatelet therapy. Four patients received targeted temperature management. The injuries and hematomas were detected using contrast-enhanced computed tomography in all cases. Three patients were treated using transcatheter arterial embolization within 6 hours following cardiopulmonary arrest, and two were resuscitated and received appropriate treatment following early recognition of their injuries. Two patients died of hemorrhagic shock with delayed intervention. Four of the five patients had excessively prolonged activated partial thromboplastin times before their interventions. CONCLUSIONS: Computed tomography should be performed as soon as possible after the return of spontaneous circulation to identify injuries and consider appropriate treatments for patients who have experienced cardiac arrest. Delayed bleeding may develop after treating hypovolemic shock and relieving arterial spasms; therefore, transcatheter arterial embolization should be performed aggressively to prevent delayed bleeding even in the absence of extravasation. This approach may be superior to thoracotomy because it is less invasive, causes less bleeding, and can selectively stop arterial bleeding sooner. A 3000-unit intravenous bolus of unfractionated heparin may be redundant; heparin-free extracorporeal cardiopulmonary resuscitation may be a more appropriate alternative. Unfractionated heparin treatment can commence after the bleeding has stopped.