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Vertebral artery dissection and pontine infarct after chiropractic manipulation
CORRESPONDENCE
171
References 1. Fisher MM, Bowey CJ, Ladd-Hudson K: External chest compression in acute asthma: A preliminary study. Crit Care Med 1989; 17:686-687 2. Watts Jh Thoracic compression for asthma. Chest 1984; 86: 505 3. Burton A, Champion P: External chest compression in acute severe asthma. Anaesth Intensive Care 1991; 19:470 4. Eason J, Tayler D, Cottam S, et al: Manual chest compression for total bronchospasm. Lancet. 1991; 337:366 5. Fewell JE, Abendschein DR, Carlson CJ: Continuous positivepressure ventilation decreases right and left ventricular end-diastolic volumes in the dog. Circ Res 1980; 46:125-132 6. Rosengarten PL, Tuxen DV, Dziukas L, et al: Circulatory arrest induced by intermittent positive pressure ventilation in a patient with severe asthma. Anaesth Intensive Care 1991 ; 19:118-121 7. Rogers PL, Schlichtig R, Miro A, et al: Auto-PEEP during CPR. An "occult" cause of electromechanical dissociation? Chest 1991; 99:492-493 8. Van der Touw T, Tully A, Amis TC: Cardiorespiratory consequences ofexpiratory chest wall compression during mechanical ventilation and severe hyperinflation. Crit Care Med 1993; 21 : 19081914
VERTEBRAL ARTERY DISSECTION AND PONTINE INFARCT AFTER CHIROPRACTIC MANIPULATION
FIGURE 3. Chest radiograph showing more intensely expanded lungs and a compressed mediastinum than those seen before resuscitation (see Fig 1).
condition, was exacerbated by rib cage compression in dogs. s This finding supports our hypothesis regarding the mechanism inducing circulatory deficiency in the present case. However, such a serious circulatory deficiency as a complication of ECC has not been reported. 1-2 Because EEC was executed by a skilled physiotherapist in the present case, it is unlikely that the complication was caused by poor technique in the execution of ECC. We assume that the increased intrathoracic pressure-induced decrease in venous return appeared more intensely in the present case than the average. Even though this circulatory complication is extremely rare, care should be taken when performing ECC considering the seriousness of circulatory complication, especially. EICHI NARIMATSU,MD, PHD SATOSHINAR& MD
Asr~ KITa,MD YOSHIHIKO KURIMOTO,MD YASUFUMIASAI, MD, PHD
Sapporo Medical University Department of Traumatology and Critical Care Medichze Sapporo Japan AKIRA ISHIKAWA,PHD,RPT
Sapporo Japan
To the Editor:-- Chiropractic has grown exponentially since its inception in this country in 1896. Every year, there are more than 10 million patients who visit a chiropractor for a variety of ailments, resulting in an average of 125 million visits annually. ~ Spinal manipulation has proven helpful to many patients for a variety of complaints, and deserves a place in the therapeutic armamentarium for the treatment of musculoskeletal disorders. Chiropractic is one of the most popular alternative therapies in the United States, and there is a public perception that injuries sustained from spinal manipulation are insignificant, as well as rare. We report a case of a left pontine infarct with vertebral artery dissection, sustained after a chiropractic spinal manipulation in a previously healthy young woman. A 33-year-old woman in good health presented to a chiropractor for treatment of a headache of several week duration. While undergoing manipulative therapy, she noted the acute onset of right-sided hemiplegia. Paramedics responding to the chiropractor's office found the patient to be alert with normal vital signs (blood pressure of 132/76 mmHg, heart rate of 86 beats/rain, and a respiratory rate of 20 breaths/min). They noted complete fight-sided hemiplegia, and transported her to a nearby hospital in full cervical spine precautions. On arrival to the emergency department, the patient remained hemiplegic, and complained of a severe headache. The patient was also suffering from severe vertigo, as well as tinnitus. Her vital signs remained relatively unchanged. Physical examination revealed a well-appearing patient who was alert and cooperative. Her head and neck showed no obvious signs of trauma, and were held midline with a cervical collar. Pupils were 4 mm, equal, and reacted briskly
Copyright © 2001 by W.B. Saunders Company 0735-6757/01/1902-0023535.00/0 doi:l 0.1053/ajem.2001.21351
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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 19, Number 2 • March 2001
to light. There was fight-sided hyperreflexia with unilateral Babinski's sign. There was left sided facial droop, and no fight-sided motor or sensory activity was appreciated. Administration of 30 mg/kg of methylprednisolone, followed by an infusion of 5.4 mg/kg/hr was given intravenously. Cervical spine radiographs were obtained which were interpreted as normal. Brain computed tomography (CT) was normal. A magnetic resonance angiography (MRA) was obtained, revealing a left pontine infarct with vertebral artery dissection. Several weeks after the incident, the patient began to regain only minimal motor activity in her fight arm. She is now in the care of a rehabilitation facility, and her neurologic deficits are only minimally improved. The technique of spinal adjustment initially used was a high cervical, high-velocity-low amplitude method (sudden thrust delivered to involved vertebrae). The occurrence of neurologic symptoms after cervical manipulation is an uncommon event in relation to the large number of manipulations performed. The risk of neurologic complications after spinal manipulation is as low as 1 case per million treatments. 2 There are only 2 cases of vertebral or basilar artery injury associated with chiropractic manipulation in the emergency medicine literature, and neither resulted in a stroke or caused permanent neurologic sequelae. 3,4 The most common site of injury to the vertebral artery appears to be the atlantoaxial joint where the artery changes from a vertical to a horizontal course. Rotating and hyperextending the neck may produce a sheafing force on the atlantoaxial joint producing intimal tearing, dissection, and thrombus formation.5 Conditions such as a vertebral bony abnormality, symptoms of vertebrobasilar insufficiency, cervical spondlyosis, myelopathy, hypermobility syndrome, infection, malignancy, and anticoagulation therapy are absolute contraindications for chiropractic intervention. 5 These conditions need to be carefully screened for before manipulation. In addition, a careful history should include the presence or absence of recent manipulations when faced with a patient with new onset vertigo. The patient in our case discussion had no known contraindications to spinal manipulation. Even admitting chiropractic's low incidence of injury, this article is important in divulging the vulnerability an average person has to such interventions. Patients, chiropractors, and physicians should all be aware of the potentially devastating neurologic outcomes possible from chiropractic manipulations. DAVID SIEGEL, MD TINA NEIDERS, MD Madigan Army Medical Center Tacoma, WA
References 1. Horn SW: The "Locked-In syndrome following chiropractic manipulation of the cervical spine. Ann Emerg Met 1983;12:648-50 2. Hosek RS, Schram SB, Silverman H, et al: Cervical manipulation. JAMA 1981 ;245:922 3. Showalter W, Esekogwu V, Newton K, et al: Vertebral artery dissection. Acad Emerg Met 1997;4:991-5 4. Cortazzo JM, Tom KB: Vertebral artery dissection following chiropractic manipulation. Am J Emerg Met 1998;16:619-20
5. Lee KP, Carlini WG, McCormick GF, et al: Neurologic complications following chiropractic manipulation: A survey of California neurologist. Neurology 1995;45:1213-5
INADVERTENT ADMINISTRATION OF NEBULIZED ACETIC ACID To the Editor:--Acetic acid ( C H 3 COOH) has many uses, including: a manufacturing component of various acetates and plastics, a preservative in foods, a solvent for gums and oils, and a pharmaceutical acidifier.1 Inhalation of acetic acid has caused reactive airway disease, pulmonary edema, pneumonitis, asthma exacerbation, and other respiratory problems. 2-4 We report a case where inhaled acetic acid produced relatively significant respiratory effects (respiratory acidosis, hypercapnea, tachypnea, and increased respiratory effort) in a 10-month old girl. The child was initially hospitalized for respiratory syncytial virus (RSV) pneumonia and started on ceftriaxone 160mg IV every 6 hours, albuterol nebulization treatments every 4 hours, and supplemental oxygen. Approximately 12 hours after admission, one of her albuterol treatments was inadvertently diluted in a 1:1 ratio, with 5% acetic acid, instead of the intended 0.9% sodium chloride diluent and administered via nebulizer for less than 30 minutes at which time the error was discovered.. The acetic acid solution was located in the patient's room on a bedside cart. It was intended to be used to cleanse and disinfect her roommate's tracheotomy site. After the respiratory therapist inadvertently administered the albuterol treatment mixed with acetic acid, the child developed an immediate cough, tachypnea, and a mild respiratory acidosis. Shortly after the accident, her arterial blood gas (ABG): pH=7.35, pCOe=59.8 mgHg, pOe=66.9 mmHg, HCO3=32.3 mmol/L, base excess=+4.8, and 02 saturation=92.2% on FiO2= 100% and continuous albuterol nebulization treatments. On her admission ABG 12 hours before this error her pCO 2 was 42 mmHg. Over the 12 hours, she received continuous albuterol nebulizer treatments while her respiratory rate increased from 40 to 65 per minute and became more labored. Her repeat ABG, 6 hours after the incident showed pH=7.30, pCO2=67.4 mmHg, pO~=71.9 mmHg, HCO3=32.9 m m o l / L base excess= +3.8, and 02 saturation=92.5% on 100% oxygen. Her vital signs at this time were: blood pressure 111/60 mmHg, pulse 143 beats/min, respiratory rate 40 breaths/rain, and a temperature of 97.2°F. The child appeared to have labored breathing and was in obvious respiratory discomfort. Seventeen hours after the incident her vital signs were: blood pressure 99/60 mmHg, pulse 159beats/rain, respiratory rate 60 breaths/min, and a temperature of 98.6°F. She required frequent suctioning of secretions, with no significant increase after the incident. Also, bilateral rales and rhonchi were unchanged from baseline. All chest radiographs obtained were significant for RSV pneumonia and showed no new infiltrates after the accident. The next morning, she became more playful and alert, the albuterol administration was changed to every 2 hours, and her vital signs were: blood pressure 118/80 mmHg, pulse 147 beats/rain, temperature of 98.0°F, and her respiratory rate decreased back to 40 breaths/min while 02 saturation on 30% oxygen was 95%. The child developed transient hypercapnea, cough, respiratory difficulty, and increased respiratory effort after the inadvertent administration of nebulized acetic acid. She was treated for approximately 24 hours with 100% oxygen and intermittent administration of nebulized albuterol. Her acute symptoms resolved within 36 hours of the accident. No metabolic consequences were seen, probably showing a lack of systemic absorption. Treatment consisted of oxygen and bronchodilators; resolution was complete
Copyright © 2001 by W.B. Saunters Company 0735-6757/01/1902-0024535.00/0 doi:l 0.1053/ajem.2001.21309
171
References 1. Fisher MM, Bowey CJ, Ladd-Hudson K: External chest compression in acute asthma: A preliminary study. Crit Care Med 1989; 17:686-687 2. Watts Jh Thoracic compression for asthma. Chest 1984; 86: 505 3. Burton A, Champion P: External chest compression in acute severe asthma. Anaesth Intensive Care 1991; 19:470 4. Eason J, Tayler D, Cottam S, et al: Manual chest compression for total bronchospasm. Lancet. 1991; 337:366 5. Fewell JE, Abendschein DR, Carlson CJ: Continuous positivepressure ventilation decreases right and left ventricular end-diastolic volumes in the dog. Circ Res 1980; 46:125-132 6. Rosengarten PL, Tuxen DV, Dziukas L, et al: Circulatory arrest induced by intermittent positive pressure ventilation in a patient with severe asthma. Anaesth Intensive Care 1991 ; 19:118-121 7. Rogers PL, Schlichtig R, Miro A, et al: Auto-PEEP during CPR. An "occult" cause of electromechanical dissociation? Chest 1991; 99:492-493 8. Van der Touw T, Tully A, Amis TC: Cardiorespiratory consequences ofexpiratory chest wall compression during mechanical ventilation and severe hyperinflation. Crit Care Med 1993; 21 : 19081914
VERTEBRAL ARTERY DISSECTION AND PONTINE INFARCT AFTER CHIROPRACTIC MANIPULATION
FIGURE 3. Chest radiograph showing more intensely expanded lungs and a compressed mediastinum than those seen before resuscitation (see Fig 1).
condition, was exacerbated by rib cage compression in dogs. s This finding supports our hypothesis regarding the mechanism inducing circulatory deficiency in the present case. However, such a serious circulatory deficiency as a complication of ECC has not been reported. 1-2 Because EEC was executed by a skilled physiotherapist in the present case, it is unlikely that the complication was caused by poor technique in the execution of ECC. We assume that the increased intrathoracic pressure-induced decrease in venous return appeared more intensely in the present case than the average. Even though this circulatory complication is extremely rare, care should be taken when performing ECC considering the seriousness of circulatory complication, especially. EICHI NARIMATSU,MD, PHD SATOSHINAR& MD
Asr~ KITa,MD YOSHIHIKO KURIMOTO,MD YASUFUMIASAI, MD, PHD
Sapporo Medical University Department of Traumatology and Critical Care Medichze Sapporo Japan AKIRA ISHIKAWA,PHD,RPT
Sapporo Japan
To the Editor:-- Chiropractic has grown exponentially since its inception in this country in 1896. Every year, there are more than 10 million patients who visit a chiropractor for a variety of ailments, resulting in an average of 125 million visits annually. ~ Spinal manipulation has proven helpful to many patients for a variety of complaints, and deserves a place in the therapeutic armamentarium for the treatment of musculoskeletal disorders. Chiropractic is one of the most popular alternative therapies in the United States, and there is a public perception that injuries sustained from spinal manipulation are insignificant, as well as rare. We report a case of a left pontine infarct with vertebral artery dissection, sustained after a chiropractic spinal manipulation in a previously healthy young woman. A 33-year-old woman in good health presented to a chiropractor for treatment of a headache of several week duration. While undergoing manipulative therapy, she noted the acute onset of right-sided hemiplegia. Paramedics responding to the chiropractor's office found the patient to be alert with normal vital signs (blood pressure of 132/76 mmHg, heart rate of 86 beats/rain, and a respiratory rate of 20 breaths/min). They noted complete fight-sided hemiplegia, and transported her to a nearby hospital in full cervical spine precautions. On arrival to the emergency department, the patient remained hemiplegic, and complained of a severe headache. The patient was also suffering from severe vertigo, as well as tinnitus. Her vital signs remained relatively unchanged. Physical examination revealed a well-appearing patient who was alert and cooperative. Her head and neck showed no obvious signs of trauma, and were held midline with a cervical collar. Pupils were 4 mm, equal, and reacted briskly
Copyright © 2001 by W.B. Saunders Company 0735-6757/01/1902-0023535.00/0 doi:l 0.1053/ajem.2001.21351
172
AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 19, Number 2 • March 2001
to light. There was fight-sided hyperreflexia with unilateral Babinski's sign. There was left sided facial droop, and no fight-sided motor or sensory activity was appreciated. Administration of 30 mg/kg of methylprednisolone, followed by an infusion of 5.4 mg/kg/hr was given intravenously. Cervical spine radiographs were obtained which were interpreted as normal. Brain computed tomography (CT) was normal. A magnetic resonance angiography (MRA) was obtained, revealing a left pontine infarct with vertebral artery dissection. Several weeks after the incident, the patient began to regain only minimal motor activity in her fight arm. She is now in the care of a rehabilitation facility, and her neurologic deficits are only minimally improved. The technique of spinal adjustment initially used was a high cervical, high-velocity-low amplitude method (sudden thrust delivered to involved vertebrae). The occurrence of neurologic symptoms after cervical manipulation is an uncommon event in relation to the large number of manipulations performed. The risk of neurologic complications after spinal manipulation is as low as 1 case per million treatments. 2 There are only 2 cases of vertebral or basilar artery injury associated with chiropractic manipulation in the emergency medicine literature, and neither resulted in a stroke or caused permanent neurologic sequelae. 3,4 The most common site of injury to the vertebral artery appears to be the atlantoaxial joint where the artery changes from a vertical to a horizontal course. Rotating and hyperextending the neck may produce a sheafing force on the atlantoaxial joint producing intimal tearing, dissection, and thrombus formation.5 Conditions such as a vertebral bony abnormality, symptoms of vertebrobasilar insufficiency, cervical spondlyosis, myelopathy, hypermobility syndrome, infection, malignancy, and anticoagulation therapy are absolute contraindications for chiropractic intervention. 5 These conditions need to be carefully screened for before manipulation. In addition, a careful history should include the presence or absence of recent manipulations when faced with a patient with new onset vertigo. The patient in our case discussion had no known contraindications to spinal manipulation. Even admitting chiropractic's low incidence of injury, this article is important in divulging the vulnerability an average person has to such interventions. Patients, chiropractors, and physicians should all be aware of the potentially devastating neurologic outcomes possible from chiropractic manipulations. DAVID SIEGEL, MD TINA NEIDERS, MD Madigan Army Medical Center Tacoma, WA
References 1. Horn SW: The "Locked-In syndrome following chiropractic manipulation of the cervical spine. Ann Emerg Met 1983;12:648-50 2. Hosek RS, Schram SB, Silverman H, et al: Cervical manipulation. JAMA 1981 ;245:922 3. Showalter W, Esekogwu V, Newton K, et al: Vertebral artery dissection. Acad Emerg Met 1997;4:991-5 4. Cortazzo JM, Tom KB: Vertebral artery dissection following chiropractic manipulation. Am J Emerg Met 1998;16:619-20
5. Lee KP, Carlini WG, McCormick GF, et al: Neurologic complications following chiropractic manipulation: A survey of California neurologist. Neurology 1995;45:1213-5
INADVERTENT ADMINISTRATION OF NEBULIZED ACETIC ACID To the Editor:--Acetic acid ( C H 3 COOH) has many uses, including: a manufacturing component of various acetates and plastics, a preservative in foods, a solvent for gums and oils, and a pharmaceutical acidifier.1 Inhalation of acetic acid has caused reactive airway disease, pulmonary edema, pneumonitis, asthma exacerbation, and other respiratory problems. 2-4 We report a case where inhaled acetic acid produced relatively significant respiratory effects (respiratory acidosis, hypercapnea, tachypnea, and increased respiratory effort) in a 10-month old girl. The child was initially hospitalized for respiratory syncytial virus (RSV) pneumonia and started on ceftriaxone 160mg IV every 6 hours, albuterol nebulization treatments every 4 hours, and supplemental oxygen. Approximately 12 hours after admission, one of her albuterol treatments was inadvertently diluted in a 1:1 ratio, with 5% acetic acid, instead of the intended 0.9% sodium chloride diluent and administered via nebulizer for less than 30 minutes at which time the error was discovered.. The acetic acid solution was located in the patient's room on a bedside cart. It was intended to be used to cleanse and disinfect her roommate's tracheotomy site. After the respiratory therapist inadvertently administered the albuterol treatment mixed with acetic acid, the child developed an immediate cough, tachypnea, and a mild respiratory acidosis. Shortly after the accident, her arterial blood gas (ABG): pH=7.35, pCOe=59.8 mgHg, pOe=66.9 mmHg, HCO3=32.3 mmol/L, base excess=+4.8, and 02 saturation=92.2% on FiO2= 100% and continuous albuterol nebulization treatments. On her admission ABG 12 hours before this error her pCO 2 was 42 mmHg. Over the 12 hours, she received continuous albuterol nebulizer treatments while her respiratory rate increased from 40 to 65 per minute and became more labored. Her repeat ABG, 6 hours after the incident showed pH=7.30, pCO2=67.4 mmHg, pO~=71.9 mmHg, HCO3=32.9 m m o l / L base excess= +3.8, and 02 saturation=92.5% on 100% oxygen. Her vital signs at this time were: blood pressure 111/60 mmHg, pulse 143 beats/min, respiratory rate 40 breaths/rain, and a temperature of 97.2°F. The child appeared to have labored breathing and was in obvious respiratory discomfort. Seventeen hours after the incident her vital signs were: blood pressure 99/60 mmHg, pulse 159beats/rain, respiratory rate 60 breaths/min, and a temperature of 98.6°F. She required frequent suctioning of secretions, with no significant increase after the incident. Also, bilateral rales and rhonchi were unchanged from baseline. All chest radiographs obtained were significant for RSV pneumonia and showed no new infiltrates after the accident. The next morning, she became more playful and alert, the albuterol administration was changed to every 2 hours, and her vital signs were: blood pressure 118/80 mmHg, pulse 147 beats/rain, temperature of 98.0°F, and her respiratory rate decreased back to 40 breaths/min while 02 saturation on 30% oxygen was 95%. The child developed transient hypercapnea, cough, respiratory difficulty, and increased respiratory effort after the inadvertent administration of nebulized acetic acid. She was treated for approximately 24 hours with 100% oxygen and intermittent administration of nebulized albuterol. Her acute symptoms resolved within 36 hours of the accident. No metabolic consequences were seen, probably showing a lack of systemic absorption. Treatment consisted of oxygen and bronchodilators; resolution was complete
Copyright © 2001 by W.B. Saunters Company 0735-6757/01/1902-0024535.00/0 doi:l 0.1053/ajem.2001.21309