Atsushi Iwai

Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake

OBJECTIVE To clarify clinical features and determine the severity of injuries in patients with crush syndrome in Hanshin-Awaji earthquake. METHODS We retrospectively reviewed medical records of 6,107 patients hospitalized in 95 hospitals, and identified 372 patients with crush syndrome. RESULTS The major sites of crush injury were in the lower extremities (74%), followed by the upper extremities (10%), and the trunk (9%). Pelvic fractures, limb fractures, and abdominal injuries were the most frequently associated injury. Patients with trunk compression and/or with abdominal injury had a higher mortality rate. A total of 50 patients (13.4%) died. The causes of death within 5 days after the earthquake were hypovolemia and hyperkalemia. Peak serum creatine kinase concentration increased with the number of crushed extremities. Mortality and the risk of acute renal failure were higher in patients with creatine kinase concentration more than 75,000 micro/L. CONCLUSIONS Peak serum concentration of creatine kinase as well as the number of injured extremities serve to estimate the severity of crush syndrome.

Morbidity and mortality of hospitalized patients after the 1995 Hanshin-Awaji earthquake

The objective of this study was to provide an overview of the morbidity and mortality of hospitalized patients during the Hanshin-Awaji earthquake. Medical records of 6,107 patients admitted to 95 hospitals (48 affected hospitals within the disaster area and 47 back-up hospitals in the surrounding area) during the initial 15 days after the earthquake were analyzed retrospectively. Patient census data, diagnoses, dispositions, and prognoses were considered. A total of 2,718 patients with earthquake-related injuries were admitted to the 95 hospitals included in our survey, including 372 patients with crush syndrome and 2,346 with other injuries. There were 3,389 patients admitted with illnesses. Seventy-five percent of the injured were hospitalized during the first 3 days. In contrast, the number of patients with illnesses continued to increase over the entire 15-day period after the earthquake. The mortality rates were 13.4% (50/372), 5.5% (128/2,346), and 10.3% (349/3,389) associated with crush syndrome, other injuries, and illness, respectively. The overall mortality rate was 8.6% (527/6,107 patients). Morbidity as well as mortality rates increased with age in patients with both injuries and illnesses. In the initial 15-day period, there was an unprecedented number of patients suffering from trauma, and they converged upon the affected hospitals. Subsequently an increased incidence of illness was observed. This survey underscores the need for adequate disaster response in such an urban situation.

Analysis of 2,702 Traumatized Patients in the 1995 Hanshin-awaji Earthquake

BACKGROUND This study was undertaken to define the factors that affected the final outcome of trauma patients in the Hanshin-Awaji earthquake. METHODS Medical records of patients admitted to 95 hospitals within or surrounding the affected area during the first 15 days after the quake were reviewed. RESULTS There were 2,702 traumatized patients. One-third of the patients were transported to hospitals in the surrounding area and had a mortality rate of 3%. The remainder, who were treated in the affected hospitals, showed a significantly higher mortality rate (8%; p < 0.05). Intensive care was provided for 513 patients, most of whom suffered from crush syndrome or from injuries to vital organs; these patients had a high mortality rate. Patients with other types of injuries had a lower mortality rate. CONCLUSION Crush syndrome and injuries to vital organs were potentially life-threatening. We believe that early transportation of such patients to undamaged hospitals with the ability to provide intensive care would have improved the survival rate.

Fluid resuscitation and systemic complications in crush syndrome: 14 Hanshin-Awaji earthquake patients.

BACKGROUND Crush syndrome is a form of traumatic rhabdomyolysis characterized by systemic involvement, in which acute renal failure is potentially life-threatening. METHODS Clinical and laboratory data of 14 crush-syndrome patients transferred to a tertiary emergency department after the Hanshin-Awaji earthquake were analyzed. The patients were buried under collapsed houses for the average of 6.7 +/- 5.7 (SD) hours (range, 1 to 24 hours). They were referred to us 6 to 250 hours after the earthquake. RESULTS Of those who arrived at our institution within 40 hours, 25% (two of eight) developed renal failure, whereas all six patients who arrived after 40 hours developed renal failure. Peak serum creatine kinase ranged from 6,677 to 134,200 U/L (51,674 +/- 41,776). Renal failure was highly associated with massive muscle damage (serum creatine kinase above 25,000 U/L) and insufficient initial fluid resuscitation (below 10,000 mL/2 days). CONCLUSIONS Prompt and adequate, if not massive, fluid resuscitation is the key to preventing renal failure after such injury.

Overview of evacuation and transport of patients following the 1995 Hanshin-Awaji earthquake.

We investigated how patients were evacuated and transported from affected hospitals in the disaster area to backup hospitals following the 1995 catastrophic Hanshin-Awaji earthquake. A retrospective review was conducted of medical records of 6107 patients hospitalized during the first 15 days after the earthquake, collected from 48 affected hospitals in the disaster area and 47 backup hospitals in the surrounding area. Of the 6107 patients, a total of 2290 (38%) were transferred to backup hospitals, consisting of 187 patients (50%) with crush syndrome, 702 (26%) with other traumas, and 1401 (41%) with illness. Of those 2290 patients, 1741 (76%) were transferred from affected hospitals to backup hospitals, while 549 patients (24%) were evacuated directly to backup hospitals. The peak in transport came during the first 4 days. The family car was the most frequently used means of transport; ambulance was used in only 26% of cases, and helicopters were used minimally. There was no notable difference in the percentage of intensive care patients and nonintensive care patients transferred to backup hospitals. The mortality rate for patients with trauma and crush syndrome was significantly higher in the affected hospitals. These results suggest that the existing emergency medical service system was not adequate for this urban earthquake. From our vantage point, we are keenly aware of the need for improved communications between hospitals, a well equipped patient transport system, and a well coordinated disaster response mechanism.

Transcatheter embolization in the treatment of massive bleeding due to maxillofacial injury

Thirty-one cases of massive bleeding due to blunt maxillofacial injuries were treated by several procedures. Blind techniques, such as nasal and/or oral packing or ligation of external carotid artery, failed to achieve hemostasis in 13 of the 18 cases (72.2%) in which they were employed before 1984. Since then, carotid angiography has documented the location of the bleeding in 12 of the 13 cases (92.3%) in which it was employed. Each of the four cases in which extravasation was visualized from the external carotid artery was successfully treated by transcatheter embolization. We conclude that selective, angiographically guided embolization can reliably achieve hemostasis in a high proportion of patients with maxillofacial injury who are in danger of exsanguination from the branches of the external carotid artery.

Intrahepatic Arterioportal Fistula after Blunt Hepatic Trauma: Case Reports

Intrahepatic arterioportal fistula (APF) was found in five out of 65 consecutive patients following blunt hepatic trauma. In four patients the fistula was located peripherally and the blood flow was small. These fistulas closed spontaneously within 3 months. However, a centrally located fistula with early visualization of the trunk of the portal vein persisted in one patient and necessitated transcatheter embolization. The APF in this patient caused portal dilatation which was detectable by CT scan. We conclude that spontaneous closure can be expected when an APF is located peripherally and the shunt flow is small, while centrally located APF with large flow require active treatment, preferably by transcatheter embolization. An APF detectable by CT scan suggests the need of intervention.

Transient and repetitive rises in blood pressure synchronized with plasma catecholamine increases after head injury. Report of two cases.

The authors report two patients with repetitive episodes of acute transient rise in blood pressure synchronized with increases in plasma catecholamine after severe head injury. In both cases, the paroxysmal hypertension occurred suddenly on the 2nd day posttrauma, and its frequency declined gradually, disappearing with time. The pathophysiological basis of this peculiar clinical manifestation is discussed.

Computed tomographic imaging of the brain in after hypoglycemia coma

SummaryA case of severe hypoglycemic coma was studied by sequential Computed Tomographic Imaging (CT) of the brain. The CT 1) was normal in the early stage, 2) subsequently showed a low density area, which was enhanced by the contrast medium, in the cerebral cortex and the boundary zone between the major cerebral arteries, and 3) revealed marked enhancement in the entire cortical region and hypodensity in the periventricular region in the late stage. These CT findings, representing the course of neural cell damage by severe hypoglycemia, are discussed from the pathophysiological viewpoint.