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左室自由壁破裂（left ventricular free wall rupture: LVFWR）は急性心筋梗塞の致死的合併症であり，とくに穿孔を伴うblow out型は瞬時に心タンポナーデを来し救命が困難な場合が多い。今回，心肺停止となったLVFWRの１例を救急外来での蘇生的開胸術（emergency department thoracotomy: EDT）により救命することができたので報告する。症例は60歳代の男性。強い胸痛を訴えショック状態で当院へ搬送された。心電図のII，III，aVF誘導でST上昇，心エコーで心嚢液貯留を認めた。急性心筋梗塞によるLVFWRと診断し，心嚢穿刺の準備中に心肺停止となった。救命のため救急外来で左肋間開胸，心嚢内血腫除去，直接心臓マッサージを実施したところ心拍再開を得た。左室下壁に梗塞部と小穿孔を認め，用手圧迫で止血を得，パッチ修復術後に血行動態は安定したため，仮閉胸した後に集中治療室へ入室した。翌日再開胸術を行ったが，接着シートは完全に固着し，穿孔部の止血は十分得られていた。重篤な合併症なく術後56日で自宅退院となり，術後14か月の現在，経過良好である。本邦では心筋梗塞後の左室自由壁破裂に対する，救急外来でのEDT実施による救命例はまだ報告されていない。心肺停止に陥ったLVFWRに対するEDTは救命のための有効な選択肢の1つと思われる。 Left ventricular free wall rupture (LVFWR) is a frequent catastrophic complication of acute myocardial infarction. We encountered a case of cardiac arrest due to blow–out type LVFWR with the patient surviving after emergency department thoracotomy (EDT). A man in his sixties was admitted to our emergency room with strong chest pain. Electrocardiography and echocardiography revealed myocardial infarction of the inferior wall and cardiac tamponade. As we attempted to perform pericardiocentesis, the patient entered cardiopulmonary arrest, so we decided to performed EDT. After opening the thorax and pericardium, numerous clots were extracted. Direct cardiac massage resulted in the heart starting to beat spontaneously. The rupture was a blowout type from a small tear at the inferior wall of the left ventricle, and pulsatile squirting bleeding was noted through the tear. We performed sutureless repair of the tear using a fibrin sealant patch (TachoSil®). The heart stroke and hemodynamic status were restored, and the patient was transferred to the intensive–care unit for further resuscitation. The day after a second–look operation, complete hemostasis seemed to have been achieved with TachoSil®alone. His postoperative course was uneventful, and he was discharged on postoperative day 56. He was doing well at 14 months after the event.

外傷性肋骨骨折に対し，持続椎弓後面ブロック（retrolaminar block: RLB）にて疼痛管理を施行した症例を経験したので報告する。48歳の女性。身長159cm，体重50kg。外傷性左第4–7肋骨骨折に対し椎弓後面ブロックを施行した。超音波ガイド下にTh4–5椎弓後面に1%リドカインと0.75%ロピバカイン（ROP）の混合液20mLを注入後，薬液でできたスペースにX線不透過性カテーテルを挿入留置し，0.2% ROP持続投与を開始した。ブロック前後で，安静時NRSは3/10から0/10へ，体動時NRSは8/10から2/10へ低下した。ROP持続注入はブロック施行後4日まで継続し，安静時のNRSは3/10以下で管理することが可能であった。持続RLBを行う際には，超音波ガイド下にてカテーテルを留置し，胸部X線写真にてカテーテル位置確認することで，良好な疼痛管理を行えると考えられる。超音波ガイド下RLBは簡便であり，硬膜外鎮痛方法に比べ重篤な合併症が少ないことから，胸部外傷に対する鎮痛方法の選択肢の一つとして考えられる。 We report a case of successful ultrasound–guided retrolaminar block (RLB) using a continuous catheter technique for relief of pain due to multiple unilateral rib fractures. A 48–year–old woman was admitted to our emergency department for blunt chest trauma. She was diagnosed with unilateral left–sided rib fractures in the T4–T7 area, and a chest tube was inserted to treat left traumatic pneumothorax. The patient had severe pain in the left hemithorax, despite the administration of oral Non–Steroidal Anti–Inflammatory Drugs. She reported pain scores of 3/10 at rest and 8/10 while moving. Ultrasound–guided RLB was planned to relieve her severe pain. With the patient in the right decubitus position, RLB was performed at the T4–T5 level using a linear probe and an in–plane needling technique. A bolus of 20mL of a mixture of 1% lidocaine with epinephrine and 0.75% ropivacaine was injected. A peripheral nerve catheter was inserted to enable the continuous administration of 0.2% ropivacaine. At 20 minutes after RLB, the patient’s pain scores were 0/10 at rest and 2/10 while moving. A continuous infusion of ropivacaine was continued for 4 days. Ultrasound–guided RLB provides excellent analgesia for the management of traumatic rib fractures.