胸骨圧迫が原因による著明な縦隔血腫から閉塞性ショックを来した1例(A case of obstructive shock from a severe mediastinal hematoma induced by chest compression)

心肺蘇生時の胸骨圧迫による合併症は比較的経験し，症例報告も散見される。しかし，胸骨圧迫によって縦隔血腫を合併し，閉塞性ショックにまで至った症例は非常に稀である。我々は胸骨骨折と内胸動脈損傷による縦隔血腫が原因で，閉塞性ショックを来した症例を救命したので報告する。症例は70歳の男性で，心肺停止状態で来院した。胸骨圧迫を継続しながら経皮的心肺補助装置を導入した。冠動脈造影検査で右冠動脈の閉塞を認め，閉塞部位に金属ステントを留置した。冠動脈カテーテル治療終了後に，単純CT検査を施行したところ，著明な縦隔血腫を認めた。縦隔血腫によって右心房が虚脱し，経皮的心肺補助装置の脱血が不良となった。緊急で剣状突起下からドレナージカテーテルを留置したが500mL/時の持続的な出血を認めたため，止血術を施行した。胸骨正中切開を行い，胸骨骨折部と左内胸動脈分枝部からの出血部をそれぞれ止血した。第4病日に経皮的心肺補助装置を離脱した。最終的に神経学的後遺症なく，長期臥床による廃用のリハビリテーション目的で転院した。 Complications due to chest compressions administered during cardiopulmonary resuscitation are relatively common. Only very rarely, however, does an obstructive shock resulting from a mediastinal hematoma occur. A 70–year–old male in cardiopulmonary arrest was admitted to the hospital. Percutaneous cardiopulmonary support was initiated as the chest compressions were continued. Coronary angiography showed occlusion of the right coronary artery, and a bare metal stent was placed at the occluded site. The patient was examined by CT after the percutaneous coronary intervention to check for complications from the percutaneous cardiopulmonary support. The CT images revealed a severe mediastinal hematoma. The percutaneous cardiopulmonary support had impeded the blood flow due to a compression of the right cardiac atrium and ventricle by the severe mediastinal hematoma. A trocar catheter was emergently inserted from below the xiphoid process. Continuous bleeding from the trocar catheter necessitated immediate hemostasis surgery. After a midline sternotomy, hemostatic treatment was applied to bleeding from the sternal fracture and branch of the left internal thoracic artery. The percutaneous cardiopulmonary support was removed on the fourth day after the surgery. The patient was ultimately transferred to another hospital for rehabilitation without neurologic deficits. CT examination can be useful for searching for fatal complications caused by chest compressions.