Jiro Shimada

Repeated embolization of intercostal arteries after blunt chest injury

To deal with an arterial bleeding from the chest wall after a blunt chest injury, embolization of the bleeding arteries can be a valuable therapeutic option, which is less invasive than a thoracotomy. However, its results are variable, being highly operator-dependent. In the present case, we performed successful emergency embolization of the 4th and 5th intercostal arteries for persistent hemorrhage following blunt trauma to the chest. Several days after the first embolization, secondary embolization was required for treating a pseudoaneurysm that was formed in the 5th intercostal artery. Although the mechanisms underlying pseudoaneurysm formation are not clearly understood, its rupture is potentially fatal. Therefore, it is essential to carefully follow-up patients who experience blunt chest injury to avoid this serious complication.

Establishment and implementation of an effective rule for the interpretation of computed tomography scans by emergency physicians in blunt trauma

IntroductionComputed tomography (CT) can detect subtle organ injury and is applicable to many body regions. However, its interpretation requires significant skill. In our hospital, emergency physicians (EPs) must interpret emergency CT scans and formulate a plan for managing most trauma cases. CT misinterpretation should be avoided, but we were initially unable to completely accomplish this. In this study, we proposed and implemented a precautionary rule for our EPs to prevent misinterpretation of CT scans in blunt trauma cases.MethodsWe established a simple precautionary rule, which advises EPs to interpret CT scans with particular care when a complicated injury is suspected per the following criteria: 1) unstable physiological condition; 2) suspicion of injuries in multiple regions of the body (e.g., brain injury plus abdominal injury); 3) high energy injury mechanism; and 4) requirement for rapid movement to other rooms for invasive treatment. If a patient meets at least one of these criteria, the EP should exercise the precautions laid out in our newly established rule when interpreting the CT scan. Additionally, our rule specifies that the EP should request real-time interpretation by a radiologist in difficult cases. We compared the accuracy of EPs’ interpretations and resulting patient outcomes in blunt trauma cases before (January 2011, June 2012) and after (July 2012, January 2013) introduction of the rule to evaluate its efficacy.ResultsBefore the rule’s introduction, emergency CT was performed 1606 times for 365 patients. We identified 44 cases (2.7%) of minor misinterpretation and 40 (2.5%) of major misinterpretation. After introduction, CT was performed 820 times for 177 patients. We identified 10 cases (1.2%) of minor misinterpretation and two (0.2%) of major misinterpretation. Real-time support by a radiologist was requested 104 times (12.7% of all cases) and was effective in preventing misinterpretation in every case. Our rule decreased both minor and major misinterpretations in a statistically significant manner. In particular, it conspicuously decreased major misinterpretations.ConclusionOur rule was easy to practice and effective in preventing EPs from missing major organ injuries. We would like to propose further large-scale multi-center trials to corroborate these results.

Patient questionnaire following closure of tracheotomy fistula: percutaneous vs. surgical approaches

BackgroundTracheotomy is an indispensable component in intensive care management. Doctors in charge of the intensive care unit (ICU) usually decide whether tracheotomy should be performed. However, long-term follow-up of a closed fistula by these doctors is rarely continued in most cases. Doctors in charge of the ICU should be interested in the long-term prognosis of tracheotomy. The purpose of this study was to evaluate whether different tracheotomy procedures affect the long-term outcome of a closed tracheal fistula.MethodsWe mailed questionnaires to patients undergoing tracheotomy in Fukushima Medical University Hospital between January 2008 and December 2010. Questions concerned problems related to perception, laryngeal function, and the appearance of a closed fistula. Patients were classified into percutaneous tracheotomy (PT) group and surgical tracheotomy (ST) group. We evaluated the statistical significance of differences in the frequency and degree of each problem between the two groups. A door-to-door objective evaluation using the original scoring system was then performed for patients who replied to the mailed questionnaire. We evaluated the percentage of patients with high scores as well as the mean scores for problems with function and appearance.ResultsWe received completed questionnaires from 28/40 patients in the PT group and 35/55 patients in the ST group. There were no significant differences in age, mean hospital stay, or APACHE II score between the groups. Regarding problems with appearance, the outcomes of PT were significantly better than those of ST with respect to self-evaluation (p = 0.04) and the frequency (p = 0.03) and degree (p = 0.02) of scar unevenness according to door-to-door evaluation. However, there were no significant differences in the frequency or degree of self-evaluation in problems with perception and function between the two groups. There were no significant differences in the frequency or degree of door-to-door evaluation of problems with function.ConclusionsThis study shows that PT might be superior to ST with respect to problems with long-term appearance. Continuous follow-up of closed tracheal fistulas can help assure that patients recovering from a critical condition experience a better return to their former lives. A systematic follow-up of post-critical-care patients is required.

Acute renal failure caused by severe coagulopathy induced by the interaction between warfarin potassium and levofloxacin: a case report

To the Editor: A 30-year-old man took warfarin potassium (4 mg/day) for several years because of idiopathic dilated cardiomyopathy (ejection fraction was 48 %, and no arrhythmia was observed). His medical regimen included aspirin (100 mg/day), digoxin (0.25 mg/day), pimobendan (20 mg/day), and atenolol (50 mg/day); glimepiride (4 mg/day), voglibose (2.7 mg/day), and allopurinol (900 mg/day) (for diabetes mellitus and hyperuricemia); and milnacipran hydrochloride (25 mg/day), fluvoxamine maleate (200 mg/day), risperidone (2 mg/day), and sodium valproate (800 mg/day) (for Asperger’s syndrome). Despite the long-term use of these medicines, neither renal disorders nor bleeding tendencies were observed [prothrombin time (PT)-international normalized ratio (INR) (PT-INR) was controlled around 1.5]. The patient presented to the emergency room with hematuria. Laboratory analyses indicated elevated white blood cell counts (20,500 cells/m) and C-reactive protein levels (4.5 mg/dl), but no anemia. We suspected urinary tract infection; therefore, levofloxacin (900 mg/day) was prescribed. After 6 days, the patient was brought to the emergency room because of hypovolemic shock resulting from nasal hemorrhage (Hb 3.7 mg/dl, Hct 10.9 %). Prothrombin time (PT) could not be determined. Acute renal failure (ARF) was suspected because of elevated blood urea nitrogen (100 mg/dl), creatinine (6.2 mg/dl), and serum potassium (6.2 mmol/l) levels. Severe hematuria with a distinct blood clot was observed. Warfarin and aspirin were discontinued; vitamin K (20 mg) was administered. Under strict observation for volume overload, Ringer’s solution and washed red cells were administered. Sufficient spontaneous urine production was maintained. Renal function recovered without hemodialysis. The hypovolemic shock caused by nasal bleeding and severe hematuria resulted in prerenal ARF; the hematoma that obstructed the urinary tract resulted in postrenal ARF. We believed both preand postrenal ARF were present. The patient’s course of PTINR and creatinine values is shown in Fig. 1. The patient had been taking warfarin for 3 years. Bleeding improved with vitamin K; therefore, the cause of coagulopathy was thought to be reinforced by the effects of warfarin. Several drugs interact with warfarin [1]. We suspected that valproate, allopurinol, and levofloxacin could interact with warfarin. ARF may have caused elevated plasma valproate and allopurinol concentrations, which could have then interacted with warfarin. However, valproate and allopurinol previously had been taken routinely, without bleeding tendencies. Thus, the newly prescribed levofloxacin was mainly responsible for this coagulopathy. Ofloxacin suppress the propagation of vitamin K-producing enteric bacteria, and thus the effects of warfarin would be enhanced. Also, warfarin and ofloxacin competitively bind with protein. Thus, the free effect of warfarin increases with the use of ofloxacin [2]. Levofloxacin and ofloxacin are both C. Nemoto (&) Y. Ikegami J. Shimada Y. Tsukada Y. Abe C. Tase Department of Critical Care and Emergency Medicine, Fukushima Medical University, 1-Hikarigaoka, Fukushima 960-1295, Japan e-mail: nemo@fmu.ac.jp

EARLY STAGE RESPONSES OF INTENSIVE CARE UNITS DURING MAJOR DISASTERS: FROM THE EXPERIENCES OF THE GREAT EAST JAPAN EARTHQUAKE

The present study investigated the role of intensive care units (ICU) during disasters, including the responses of our ICU following the Great East Japan Earthquake on March 11, 2011. Our ICU comprises 8 beds for postoperative inpatients and those with rapidly deteriorating conditions; 20 beds in an emergency unit for critically ill patients; and 17 beds for neonates. It is important to secure empty beds when a major disaster occurs, as was the case after the Great Hanshin Earthquake, due to the resulting large numbers of trauma patients. Therefore, each ICU section cooperated to ensure sufficient space for admissions following the Great East Japan Earthquake. However, unlike the Great Hanshin Earthquake, securing beds was ultimately unnecessary due to the nature of the recent disaster, which also consisted of a subsequent tsunami and nuclear accident. Therefore, air quality monitoring was required on this occasion due to the risk of environmental radioactive pollution from the nuclear disaster causing problems with artificial respiration management involving atmospheric air. The variability in damage arising during different disasters thus requires a flexible response from ICUs that handle seriously ill patients.

Activation Intervals for a Helicopter Emergency Medical Service in Japan

INTRODUCTION Prehospital time is crucial for treating acute disease; therefore, it is important to activate helicopter emergency medical services (HEMS) promptly. We investigated the differences in the activation intervals (the time elapsed from receiving the emergency call to the time of HEMS request) under various conditions to evaluate the current status of HEMS-related prehospital triage in Japan. METHODS We retrospectively investigated activation intervals under exogenous (trauma, n = 553; intoxication, n = 56; and burns, n = 32) and endogenous conditions (acute coronary syndrome [ACS], n = 47; and stroke, n = 173) between January 31, 2008, and January 31, 2012, by reviewing flight records. RESULTS Activation intervals were trauma (14.3 ± 11.5 min), intoxication (10.3 ± 8.6 min), burns (15.0 ± 13.1 min), ACS (17.9 ± 14.6 min), and stroke (19.1 ± 13.1 min). One-way analysis of variance showed a significant difference between exogenous and endogenous groups (P < .001). Post-hoc analysis using Tukeys honestly significant difference test showed significant differences between ACS and intoxication (P < .05), stroke and intoxication (P < .001), and stroke and trauma (P < .001). CONCLUSIONS Endogenous conditions had longer activation intervals, which may reflect a lack of mechanisms assessing their severity. We are considering developing new triage criteria for dispatchers.

Possible additional role for nasal jet oxygen insufflation

1. Li Q, Xie P, Zha B, Wu Z, Wei H. Supraglottic jet oxygenation and ventilation saved a patient with ‘cannot intubate and cannot ventilate’ emergency difficult airway. J Anesth. 2017;31:144–7. 2. Japanese Society of Anesthesiologists. JSA airway management guideline 2014: to improve the safety of induction of anesthesia. J Anesth. 2014;28:482–93. 3. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13. 4. Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70:323–9.

Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: A nationwide cross-sectional study

BackgroundAlthough human and equipment resources, proper training, and the verification of endotracheal intubation are vital elements of difficult airway management (DAM), their availability in Japanese emergency departments (EDs) has not been determined. How ED type and patient volume affect DAM preparation is also unclear. We conducted the present survey to address this knowledge gaps.MethodsThis nationwide cross-sectional study was conducted from April to September 2016. All EDs received a mailed questionnaire regarding their DAM resources, airway training methods, and capnometry use for tube placement. Outcome measures were the availability of: (1) 24-h in-house back-up; (2) key DAM resources, including a supraglottic airway device (SGA), a dedicated DAM cart, surgical airway devices, and neuromuscular blocking agents; (3) anesthesiology rotation as part of an airway training program; and (4) the routine use of capnometry to verify tube placement. EDs were classified as academic, tertiary, high-volume (upper quartile of annual ambulance visits), and urban.ResultsOf the 530 EDs, 324 (61.1%) returned completed questionnaires. The availability of in-house back-up coverage, surgical airway devices, and neuromuscular blocking agents was 69.4, 95.7, and 68.5%, respectively. SGAs and dedicated DAM carts were present in 51.5 and 49.7% of the EDs. The rates of routine capnometry use (47.8%) and the availability of an anesthesiology rotation (38.6%) were low. The availability of 24-h back-up coverage was significantly higher in academic EDs and tertiary EDs in both the crude and adjusted analysis. Similarly, neuromuscular blocking agents were more likely to be present in academic EDs, high-volume EDs, and tertiary EDs; and the rate of routine use of capnometry was significantly higher in tertiary EDs in both the crude and adjusted analysis.ConclusionsIn Japanese EDs, the rates of both the availability of SGAs and DAM carts and the use of routine capnometry to confirm tube placement were approximately 50%. These data demonstrate the lack of standard operating procedures for rescue ventilation and post-intubation care. Academic, tertiary, and high-volume EDs were likely to be well prepared for DAM.

Investigation of final destination hospitals for patients in helicopter emergency medical services (doctor-helicopter) in Fukushima Prefecture

PurposeIn using an emergency medical service helicopter with an emergency medicine doctor on board (doctor–helicopter), transporting all patients to the University Hospital (base hospital for the helicopter) could cause a chronic bed shortage at the University Hospital. It is also disadvantageous for patients from distant areas. We investigated whether appropriate hospital selections are being carried out in Fukushima Prefecture.MethodsThe subjects of the study were patients who were transported by doctor–helicopter since the services started. We investigated the medical conditions of patients at emergency scenes, whether they were transported to a hospital inside or outside the region, the means of transportation, and the final destination hospital.ResultsThere were 450 flights, of which 295 were to emergency scenes, involving 307 patients. The majority were trauma patients (191 patients, 62.2%). The final destination hospital was the University Hospital for 104 patients (33.9%); 99 patients (30.3%) were transported to three emergency and critical care medical centers (ECCMCs) in other regions. Most patients were transported to appropriate hospitals in the respective regions. The means of transportation from the emergency scene was by doctor–helicopter in the largest number of cases (223 patients, 72.6%), and the final destination hospital was ECCMCs in 81.6% of cases.ConclusionPatients from emergency scenes are transported by doctor–helicopter to appropriate hospitals in the region, and hospitals in each region are cooperating with the doctor–helicopter operations.