Katsunori Mochizuki

Importance of respiratory rate for the prediction of clinical deterioration after emergency department discharge: a single-center, case-control study

The purpose of the present study was to investigate the predictors of clinical deterioration soon after emergency department (ED) discharge.

Impact of a negative D-dimer result on the initial assessment of acute aortic dissection

BACKGROUND D-dimer shows high sensitivity but low specificity for the diagnosis of acute aortic dissection (AAD). Previous reports indicated that negative D-dimer patients have shorter dissection length. However, whether patients with negative D-dimer results have a good prognosis is unknown. This study aimed to elucidate the clinical characteristics and implications of a negative D-dimer result on AAD diagnosis. METHODS The study group comprised 126 patients (71 males, 55 females; mean age, 69 ± 11 years) with AAD admitted to our hospital between April 2009 and March 2015. Blood samples on presentation were used for D-dimer measurement. Clinical characteristics and outcomes were assessed. RESULTS Nine (7.1%) and 117 (92.9%) exhibited negative and positive D-dimer results, respectively. The negative group showed a significantly lower extension score and a higher platelet count than the positive group. Multivariate analysis demonstrated that platelet count (odds ratio, 1.31 (1.09-1.58), p = 0.003) and extension score (odds ratio, 0.56 (0.33-0.96), p = 0.03) were significantly related to a negative result. Notably, 44% of patients in the negative group had type A dissection and 33% underwent an emergency operation due to cardiac tamponade. CONCLUSION We found that high platelet count and low extension score were independent factors related to a negative D-dimer result. Even if the length of the dissection is short, an emergency operation is necessary in some patients with a negative D-dimer result. Physicians should recognize that a negative D-dimer result alone cannot exclude patients with fatal AAD conditions.

Crossed Cerebellar Diaschisis in Status Epilepticus.

Crossed cerebellar diaschisis (CCD) is an interesting phenomenon which classically refers to the depressed blood flow and metabolism affecting one cerebellar hemisphere after a contralateral hemispheric infarction. However, CCD can also be caused by a prolonged seizure. We herein report a case of CCD due to status epilepticus in a patient who showed unique magnetic resonance imaging findings.

Diffuse Alveolar Hemorrhage Associated with Edoxaban Therapy

Introduction. The main adverse effect of anticoagulant therapy is bleeding, and major bleeding, including intracranial, gastrointestinal, and retroperitoneal bleeding, has been reported as an adverse effect of edoxaban, a direct oral anticoagulant (DOAC). Bleeding during systemic anticoagulation with edoxaban presents a therapeutic conundrum, because there is currently no safe or efficacious reversal agent to stop major bleeding. Case Report. A 51-year-old woman had multiple traumatic injuries, including lower limb fractures. On day 8, she developed deep venous thrombosis, and edoxaban was administered orally. On day 38, she developed fungemia, which was treated with an antifungal drug. On day 43, she presented with dyspnea. Chest computed tomography scan showed bilateral diffuse ground-glass opacities in the whole lung fields. The results of the subsequent workup (i.e., serum levels of the antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane antibody) and microbiological study were unremarkable. Based on these findings, her condition was diagnosed as diffuse alveolar hemorrhage (DAH) associated with edoxaban therapy. The lung opacities disappeared spontaneously after edoxaban therapy was discontinued. Conclusion. DAH is a dangerous complication associated with edoxaban therapy. DOACs, including edoxaban, should be prescribed with caution, especially for patients in a critical condition.

Influence of body position during Heimlich maneuver to relieve supralaryngeal obstruction: a manikin study

To study the most effective body position for Heimlich maneuver.

Successful treatment of a case with concurrent ingestion of carbamazepine overdose and grapefruit juice

We report a case with concurrent ingestion of carbamazepine (CBZ) overdose and grapefruit juice. A 23‐year‐old man, with a history of epilepsy, was admitted to our emergency department 2 h after ingesting 10 g CBZ with 1 L grapefruit juice. On arrival, the patients Glasgow Coma Scale score was 9 and he showed signs of restlessness. Grapefruit juice‐like gastric fluid, with tablet residue, was observed in his stomach after we inserted a gastric tube. Our initial test detected a blood CBZ level of 41.5 mg/L.

Rupture of gastrointestinal stromal tumor presenting with sudden onset chest and back pain and accompanied by gastric dilatation

A 72‐year‐old man with hypertension was admitted with acute‐onset chest and back pain followed by epigastralgia. He was transported by helicopter due to suspected acute aortic dissection. Systolic blood pressures were equal in both arms. Physical examination showed epigastric tenderness without rebound. Blood tests showed leukocytosis. Electrocardiogram and echocardiogram were normal. Abdominal radiography showed acute gastric dilatation with an air‐outlined large mass‐like shadow. Abdominal computed tomography revealed a 6‐cm exophytic mass and large intramural hematoma in the lesser curvature of the gastric body.

Complete cervical tracheal transection due to blunt trauma

A 31‐year‐old man was caught up in the rotor of a snow‐removing truck. He was diagnosed with tension pneumothorax and managed with tube thoracostomy in the ambulance. But he was left with respiratory discomfort. Computed tomography scan suggested the diagnosis of complete cervical tracheal transection.

138: PREVALENCE OF TAKOTSUBO CARDIOMYOPATHY IN EMERGENCY DEPARTMENT.

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) ST elevation by definition) and progressive symptoms, patients who ‘rule-in’ for an MI with a second or later sample cardiac enzyme elevation, create a poorly described subset of NSTEMI patients. Methods: All patients presenting to the ED and receiving EKG and Cardiac enzyme for chest pain were included in a consecutive, observational study over a 12 month period NSTEMI meant no ST elevation, WHO criteria for chest pain and elevation of CK-MB > 3.0 or Tn I > 0.15 or elevation of both markers. The two groups were divided into those with a cardiac enzyme elevation on initial enzyme or on a later enzyme drawn between 4–6 hr later and repeated 8–12 hr after the first enzyme was drawn. Confirmatory Chart Review for All ED patients diagnosed with Nstemi by Cardiology Admitting Team, patients Followed for 3 mo Post Diagnosis for MACE. Results: 6 Month Study of consecutive patients presenting to ED: 2,894 Chest Pain Patients were admitted, with 4.8% of patients having an AMI (141 Diagnosed AMI). Of that 105 met NSTEMI Criteria with 60 Pts (Early) Initial Cardiac marker elevation (Troponin I) Mean 2.2 hr to diagnosis, and 45 Pts (DD) Delayed Cardiac marker elevation Diagnosed within 5–13 hr. Early N-NSTEMI Delayed N-STEMI Mean Age 64.3 yr 65 yr NS Gender 62% Male 74 % Male p=.05 LOS 6.4 days 9.6days p= .05 83% Cath 94% Cath p = .05 Mean time to Cath: 16 hr 57.6 hr p = .01 In Hospital Mortality: 6.4% 4 % NS CABG: 15% 26% p= .04. Conclusions: The ED groups for N-STEMI were well matched for Demographics. The Delayed Diagnostic Group had delays to discovery of critical lesions (Cath) and Greater Rates of Need for CABG with Longer Hospital Stay. Better early detection protocols and testing are needed.

A foreign body in the nasopharynx: missing tooth mystery solved

A 72-yr-old male was admitted to the emergency department in asystole due to accidental hypothermia. Cardiopulmonary resuscitation was undertaken, and tracheal intubation, though difficult, was accomplished. Extracorporeal rewarming was subsequently initiated. Brain computed tomography (CT) was performed to assess the patient’s neurologic status, and immediately following, he was transferred to the intensive care unit (ICU). The CT scan revealed a high-density tabletlike foreign body (2.390.9 cm) in the nasopharynx (Figure A, B; arrow). We were informed at ICU admission that the patient had lost a tooth; however, chest and abdominal radiographs were normal, and we could not find the tooth in the oral cavity. Two hours after admission, the patient’s hemodynamic status normalized and extracorporeal rewarming was discontinued five hours following his ICU admission. On day 2 of admission, transnasal endoscopy was undertaken to search for the foreign body, which was subsequently removed using forceps and identified as a tooth (Figure C). Teeth may be injured if laryngoscopy is particularly difficult. If the lost tooth cannot be found, chest and abdominal imaging must be performed to determine if the tooth had been aspirated or had entered the gastrointestinal tract. In our case, there was uncertainty surrounding the CT