title: Severe transmyocardial ischemia in a patient with tension pneumothorax.
abstract: OBJECTIVE
  To report tension pneumothorax (TP) as a cause of severe myocardial ischemia.
  
  
  METHODS
  Clinical case report.
  
  
  METHODS
  Medical intensive care unit of a university hospital.
  
  
  METHODS
  One patient with severe shock attributable to right TP after unsuccessful percutaneous central venous catheterization.
  
  
  METHODS
  Blood pressure, electrocardiogram (ECG), chest radiograph, and echocardiography during and after shock.
  
  
  RESULTS
  On admission the patient was in profound state of shock (heart rate 140 beats/min, blood pressure 65/30 mm Hg). Twelve-lead ECG showed pronounced ST segment elevation in leads II, III, aVF, and V4-V6. Chest radiograph revealed right TP with complete displacement of the mediastinum and the heart to the left side. Immediate right-sided tube thoracostomy resulted in reexpansion of the lung followed by instantaneous hemodynamic and respiratory improvement as well as nearly complete resolution of the ECG changes. Peak value of the creatine phosphokinase was 4140 U/L without significant elevation of the MB isoenzyme at any time. Moreover, the initial hypokinesia of the posterior and lateral left ventricular wall resolved completely, as demonstrated by echocardiography.
  
  
  CONCLUSIONS
  The specific condition of TP may lead to impaired systolic and diastolic coronary artery blood flow affecting ventricular repolarization and T-wave configuration in ECG indicative of transmyocardial ischemia. General symptoms, namely hypotension, tachycardia, and hypoxemia, are likewise typical for cardiogenic shock attributable to myocardial infarction. Yet any therapeutic measure directed toward revascularization, such as thrombolysis or even percutaneous transluminal coronary angioplasty, would have had devastating consequences. Therefore, thorough physical examination of our patient was pivotal in disclosing the true origin of profound shock.
authors.affiliation: Medical Clinic I, University of Aachen, Germany.
authors.forename: U
authors.initials: U
authors.lastname: Janssens
authors.forename: K C
authors.initials: KC
authors.lastname: Koch
authors.forename: J
authors.initials: J
authors.lastname: Graf
authors.forename: P
authors.initials: P
authors.lastname: Hanrath
mesh_terms: D000368:Aged; D003422:Critical Care; D003937:Diagnosis, Differential; D004562:Electrocardiography; D005260:Female; D006329:Heart Conduction System / Q000503:physiopathology; D006801:Humans; D017202:Myocardial Ischemia / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D011030:Pneumothorax / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D012769:Shock / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D013907:Thoracostomy; D016277:Ventricular Function, Left / Q000502:physiology