Masato Miyauchi

Traumatic Renal Artery Occlusion Treated with an Endovascular Stent-The Limitations of Surgical Revascularization : Report of a Case

When renal artery occlusion occurs secondary to blunt trauma, the recovery rate of renal function after open revascularization is varied and far from satisfactory. Although the optimal treatment for this type of injury has not been established, percutaneous revascularization by endovascular stenting has recently been advocated for patients with unilateral renal artery occlusion. We herein report a case of blunt renal artery occlusion treated with an endovascular stent. After the placement of the stent, renal arteriography showed multiple nonflow-limiting contrast defects in the distal renal arteries, suggesting peripheral thrombosis. Although the duration of warm renal ischemia appears to be the crucial determinant of renal function, multiple thrombi in the distal renal arteries, which would be undetectable during open surgery, could also affect the functional outcome. The presence of these thrombi may explain the limited success of surgical revascularization in such cases.

Utility of Upper Gastrointestinal Endoscopy for Management of Patients with Roundup® Poisoning

Introduction: Roundup® is a herbicide widely used in Japan in gardening and agriculture. When ingested, Roundup is highly toxic, but gastrointestinal decontamination, including gastric lavage, is not routinely performed after ingestion. Endoscopy may be useful in managing individuals with liquid herbicide poisoning, by identifying gastric residual contents, assessing mucosal damage and retrieving herbicide directly by aspiration. Case report: A 73 year old, 40 kg female with a history of depression was transported to our emergency room by ambulance 1 h after attempting suicide by ingesting 100 ml Roundup, which contains 48% glyphosate-potassium, and 52% surfactant and water. This volume was below a fatal dose (<5000 mg/kg), but may have caused organ dysfunction and mucosal damage. After confirming respiratory and circulatory stability and after obtaining informed consent from the patient, endoscopy (XQ 260; Olympus, Tokyo, Japan) was performed in the emergency room to retrieve residual herbicide. About 80 ml of herbicide in the stomach were aspirated endoscopically with only mild erosion observed in the mucosa of the stomach. The patient was able to resume oral intake 2 days after endoscopy and was discharged without any complications on day 5. Conclusion: Endoscopy may be useful in cases of liquid poisoning including, Roundup, both to determine the amount of residual toxin and to remove it from the stomach.

Successful retrieval using ultrathin transnasal esophagogastroduodenoscopy of a significant amount of residual tricyclic antidepressant following serious toxicity: a case report

BackgroundIn Japan, ultrathin transnasal esophagogastroduodenoscopy (EGD) with a 4.9-mm diameter endoscope (Olympus XP260) is routinely used to examine the upper gastrointestinal tract. This procedure does not require sedation and does not affect vital signs. Gastric lavage is not empirically employed in the management of all poisoning patients. It is considered only for potentially life-threatening overdoses when the procedure can be performed within 1 h of ingestion of the poison. However, there are no absolute indications for gastric lavage. EGD may increase the indications, efficiency and safety of gastric lavage in poisoning patients.FindingsA 35-year-old female was admitted to our emergency department 2 h after ingesting multiple drugs, including a critical dose of the tricyclic antidepressant (TCA) amitriptyline, at which time she was confused and had a Glasgow Coma Scale score of 8 (E1V2M5). Endotracheal intubation was performed. To confirm the type of TCA and in order to determine whether gastric lavage was required, we decided to perform EGD. Endoscopy demonstrated adherence of residual drugs to the stomach wall, in a soluble form and not as a mass. Hence, gastric lavage was performed via the EGD to avoid passage of these drugs into the small bowel. The patient was extubated on day 2, without the development of complications such as aspiration pneumonia, and was discharged on day 5.ConclusionEGD may be useful in poisoning patients for determining the amount of residual drug in the stomach, also allowing direct observation of the effectiveness of gastric lavage.

Evaluation of Residual Toxic Substances in the Stomach Using Upper Gastrointestinal Endoscopy for Management of Patients With Oral Drug Overdose on Admission: A Prospective, Observational Study

AbstractThe guidelines on the indications for gastric lavage were published in 1997, and a less-aggressive initial approach has been used for poisoned patients. Clinical studies have shown that the outcomes of retrieval of residual toxic substances in the stomach are variable and that no beneficial effect is obtained. However, the presence of residual toxic substances in the stomach before gastric lavage has not been estimated. The objective of this study was to evaluate the residual stomach contents on admission of patients with oral drug overdoses using upper gastrointestinal endoscopy.A 2-year prospective study of 167 patients with oral drug overdoses was performed. Endoscopy was performed on admission to observe the gastric body, fornix, and pyloric antrum. Patients were classified into 3 groups according to the digestive phase (tablet/food phase, soluble/fluid phase, and reticular/empty phase). The groups were compared with respect to time elapsed since ingestion, and numbers and variety of orally overdosed drugs.The numbers of patients in each phase were as follows: tablet/food phase, 73; soluble/fluid phase, 50; and reticular/empty phase, 44. The tablet/food and soluble/fluid phase groups contained the greatest numbers of patients who presented within 1 to 2 hours since ingestion. In the tablet/food group, only 12 of 73 patients (16%) presented within 1 hour since ingestion, and 3 patients presented >12 hours since ingestion. In the soluble/fluid phase group, only 9 of 50 patients (18%) presented within 1 hour since ingestion, and 2 patients presented >12 hours since ingestion. The reticular/empty phase group contained the greatest number of patients presenting within 2 to 4 hours since ingestion, and 3 patients presented within 1 hour since ingestion. The residual stomach contents before lavage were variable in all of the groups.The residual gastric content before the performance of gastric lavage is variable in overdosed patients on admission. This may influence the efficiency of gastric lavage with respect to retrieval of residual toxic substances in the stomach. This study may contribute to the development of a strategy for treating patients who have orally overdosed on drugs in the future.

Prehospital removal improves neurological outcomes in elderly patient with foreign body airway obstruction

Objective: In Japan, the number of patients with foreign body airway obstruction by food is rapidly increasing with the increase in the population of the elderly and a leading cause of unexpected death. This study aimed to determine the factors that influence prognosis of these patients. Methods: This is a retrospective single institutional study. A total of 155 patients were included. We collected the variables from the medical records and analyzed them to determine the factors associated with patient outcome. Patient outcomes were evaluated using cerebral performance categories (CPCs) when patients were discharged or transferred to other hospitals. A favorable outcome was defined as CPC 1 or 2, and an unfavorable outcome was defined as CPC 3, 4, or 5. Results: A higher proportion of patients with favorable outcomes than unfavorable outcomes had a witness present at the accident scene (68.8% vs. 44.7%, P = 0.0154). Patients whose foreign body were removed by a bystander at the accident scene had a significantly high rate of favorable outcome than those whose foreign body were removed by emergency medical technicians or emergency physician at the scene (73.7% vs. 31.8%, P < 0.0075) and at the hospital after transfer (73.7% vs. 9.6%, P < 0.0001). Conclusions: The presence of a witness to the aspiration and removal of the airway obstruction of patients by bystanders at the accident scene improves outcomes in patients with foreign body airway obstruction. When airway obstruction occurs, bystanders should remove foreign bodies immediately.

Gymnastic Formation-related Injury to Children in Physical Education

OBJECTIVE Current data indicate that the rate of trauma in children during gymnastic formation is increasing, especially while creating a structure with a certain height, such as the human pyramid. The goal of the present study was to clarify the clinical characteristics of these injuries. METHODS In this single-institution review, all children treated for a gymnastic formation-related injury at Nippon Medical School Hospital from 2013 through 2015 were identified through the institutions registry. The injury mechanism was classified, and injury severity, interventions, and outcome were examined. RESULTS Eight children were treated for a gymnastic formation-related injury. They were 7 boys and 1 girl aged 10 to 15 years (mean age, 13.1±1.8 years). Neurotrauma ranging from concussion to spinal cord injury without radiographic abnormality occurred in 6 patients (75%). No intracranial hemorrhagic lesions were detected. The Glasgow Coma Scale score on arrival was 15 in all 8 patients, and neurological deficits were present in 1 patient. No patient required surgical intervention. All patients made a full recovery after discharge from the hospital. No patients died. The average follow-up period was 2.1±0.9 weeks. CONCLUSIONS Neurotrauma is a frequent result of gymnastic formation accidents in children. Healthcare workers and teachers should recognize this type of injury, and public education that targets parents should be introduced.

Pseudostenosis of the external iliac artery in a patient with blunt pelvic trauma.

A 44-year-old man was crushed by a container weighing 300 kg that fell on his pelvis. On arrival at our institution, the patient complained of pelvic pain. Physical examination revealed a systolic blood pressure of 104/76 mm Hg, a heart rate of 108 bpm, a respiration rate of 20/min, and a subcutaneous hematoma of the left buttock. Primary and secondary surveys were completed, and the findings of significance were pelvic fracture and a retroperitoneal hematoma on pelvic computed tomography scans. Soon after admission to the intensive care unit, his hemodynamic status deteriorated despite fluid resuscitation and blood transfusion, indicating the need for emergency hemostasis, and the patient was taken to the interventional radiology suite. Pelvic angiography revealed extravasation from a branch of the internal iliac artery, which was embolized with gelatin sponge particles. Significant stenosis was also seen in multiple regions of the left external iliac artery on the angiogram, suggesting arterial injury (Fig. 1). On exploration of the left iliac vessels, mild spasm of the external iliac artery was seen. Because intimal injury could not be ruled out, the artery was dissected completely, but no intimal injury or intraluminal blood clots were found on direct inspection (Fig. 2). The artery was closed with a continuous suture of 6-0 polypropylene. An iliac angiogram obtained at 6 days after surgical exploration revealed no irregularities of the left iliac arteries (Fig. 3). Catheter-induced vasospasm of small arteries, such as the coronary arteries, has been reported to be triggered by mechanical stimulation of an increase in vasomotor tone and myogenic reflexes. However, the phenomenon has rarely been documented in large arteries. Catheter-induced vasospasm of the iliac arteries during coronary angiography has only been described by a few authors. Mechanical distortion of tortuous a vessel, i.e., straightening of the vessel by the catheter (the “accordion effect”), may mimic spasm or dissection during angiography and has been suggested as the mechanism of pseudostenosis. Although multiple stenoses of the external iliac artery near the pelvic fracture associated with a large retroperitoneal hematoma were present in our patient, suggesting direct damage to the iliac vessels, surgical exploration proved to be unnecessary. Therefore, this case emphasizes the importance of knowing about the possibility of pseudostenosis secondary to catheter-induced straightening of arterial tortuosity, since its recognition may help to avoid complications related to unnecessary intervention.