Naoyuki Kaneko

Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest

The effects of mild hypothermia (MH) were investigated. From 1995 to 1996, 28 adult patients with out-of-hospital cardiopulmonary arrest (CPA) had return of spontaneous circulation and survived for more than two days. Thirteen patients were in the MH group. In the MH group, core temperature was maintained between 33 and 34 degrees C for 48 h, and then re-warmed to a temperature of 37 degrees C, at a rate of no greater than 1 degrees C per day. Fifteen patients, admitted before the MH protocol was instituted, were in the control group. Despite the fact that the number of witnessed arrests in the control group were greater than in the MH group, there were both more survivors (7/13 vs. 5/15) and more fully recovered patients (3/13 vs. 1/15) in the MH vs Control groups. Eleven of 13 MH patients, as compared to 6/15 controls developed pneumonia. Our study, although preliminary, suggests that MH might confer improved outcome, as has been shown in animal models, after CPA. This treatment is associated with an increase in pneumonic complications.

Hyperthermia: is it an ominous sign after cardiac arrest?

OBJECTIVE To clarify the clinical characteristics of hyperthermia at an early stage after resuscitation from cardiac arrest (CA). MATERIALS AND METHODS We reviewed the medical records of 43 adult patients with non-traumatic out-of-hospital CA, who survived for longer than 24 h after admission to our intensive care unit (ICU) between January, 1995, and December, 1998. The patients were divided into two groups: a clinical brain death (CBD) group (n=23) and a non-CBD group (n=20), and various factors relating to hyperthermia were compared between the two groups. RESULTS The mean value of peak axillary temperatures within 72 h of admission was 39.8+/-0.9 degrees C for the CBD group, which was significantly greater than 38.3+/-0.6 degrees C for the non-CBD group (P<0.0001). The time of occurrence of the peak axillary temperature was at 19+/-16 h of admission in the CBD group and 20+/-18 h in the non-CBD group (not significantly different). There were no significant differences in risk factors relating to the occurrence of hyperthermia between the two groups, except for the number of patients who received epinephrine at ICU. In 23 patients with a peak axillary temperature of > or =39 degrees C during the first 72 h of hospitalization, brain death was diagnosed in 20 patients, whereas only 3 of 20 patients having a peak axillary temperature of <39 degrees C developed brain death (odds ratio, 37.8; 95% confidence interval, 6.72-212.2). CONCLUSION Hyperthermia at an early stage after resuscitation from CA may be associated with the outcome of brain death.

Measurement of interleukin-6, interleukin-10, and tumor necrosis factor-alpha levels in tissues and plasma after thermal injury in mice☆

BACKGROUND Cytokines are important modulators of physiologic alterations after thermal injury. Indeed, an increase in the level of circulating cytokines has been documented after thermal injury. However, the mechanism of the increase has not been clarified. We determined cytokine levels in local tissue after thermal injury to identify the tissues responsible for the increase. METHODS Female C57BL/6 mice each received a 20% full-thickness burn injury. Blood, burned skin, unburned skin, muscle underlying the burn, and muscle of the thigh, liver, spleen, and mesenteric lymph node were sampled at 1, 2, 4, 8, and 24 hours after injury. Uninjured control mice were treated similarly. The samples were cultured, and concentrations of tumor necrosis factor-alpha, interleukin-6 (IL-6), and IL-10 in the culture media were measured by using an enzyme-linked immunosorbent assay. RESULTS IL-6 levels in unburned skin were significantly increased at 1 hour and decreased at 24 hours, compared with the control. IL-6 levels in muscle underlying the burn were significantly decreased at 8 hours. No elevation of plasma IL-6 levels was observed after injury. Neither tumor necrosis factor-alpha IL-10 was detected in any tissue. CONCLUSIONS Results indicate that unburned skin may be a major source of IL-6 production after thermal injury and may contribute to the physiologic alterations occurring after such injury.

Indications for Transcatheter Arterial Embolization in Persistent Hemothorax caused by Blunt Trauma

BACKGROUND To confirm the usefulness of contrast-enhanced computed tomography (CECT) and the efficacy of transcatheter arterial embolization (TAE) in patients, who undergo tube thoracostomy for hemothorax secondary to blunt chest trauma. MATERIALS CECT was performed at admission in patients, who suffered blunt chest trauma but did not require an emergent thoracotomy. Pulmonary injuries with intrapulmonary hematomas or traumatic pneumatoceles or both on computed tomography images were diagnosed as pulmonary lacerations (PL). The size of the pulmonary injuries with the PL was measured as percent volume (volume of the PL/volume of the lung). Rib fracture displacement was measured on computed tomography images and expressed as parallel and transverse displacement of the fractured ribs (PD and TD, respectively). Patients with an injury to a thoracic great vessel (e.g., aortic injury) were excluded. RESULTS CECT of the chest was performed on 154 of 976 consecutive patients with blunt torso trauma. Thirty-four patients have PL without a great vessel injury. Tube thoracostomy was performed at 38 sites in 29 patients. After the initial bloody drainage, the mean drainage during the first hour was 81.2 mL/h +/- 137 mL/h. The mean percent volume of the PL was 29.0% +/- 15.4%. The mean PD was 12.2 mm +/- 10.4 mm. The PD and the TD correlated with the hourly drainage (p = 0.001, p < 0.001, respectively). No correlation was found between the percent volume of PL and hourly drainage (p = 0.11). Of the 38 thoracostomy sites, 6 had a blood loss of > or =200 mL/h. Contrast extravasation on CECT was observed in five of these six sites, and angiography was performed. All five sites had contrast extravasation from an intercostal artery, and TAE was successfully performed. CONCLUSION Intercostal arterial bleeding should be suspected in patients with persistent hemothorax > or =200 mL/h and large displacement of a fractured rib. In such cases, CECT should be performed and TAE is indicated if contrast extravasation is observed.

Anatomic variations of the renal vessels pertinent to transperitoneal vascular control in the management of trauma

BACKGROUND Operative exposure and control of the renal vessels through a transabdominal retroperitoneal (TARP) approach has been advocated for emergency management of renal trauma. The pertinent anatomic variations of the renal vasculature have not been well described. METHODS In 190 cadavers, the renal vessels were examined. The first 20 cadavers were examined via TARP approach, and 170 cadavers were investigated after evisceration. The findings were interpreted as they might relate to the TARP approach to the renal pedicle. RESULTS The renal artery (RA) originated dorsally or inferiorly to the left renal vein (RV) in 70% of the cadavers on each side. Additional RAs emerging below the inferior mesenteric artery were present in 2.4% of cadavers on the right side and 1.8% on the left. Approach to the inferior vena cava (IVC) adequate for the management of trauma through the TARP approach was impossible, although it has been recommended in some research. The clinically significant incidence of variations was as follows: 47% multiple RAs, 13% multiple RVs, and 50% of at least 1 RA that coursed superior to the right RV on the right margin of the IVC. CONCLUSION Knowledge of the varied anatomy of the renal vessels facilitates a safe approach to the kidneys in trauma management. The varied and unpredictable anatomy of the renal vasculature requires prompt change when the TARP approach fails to provide access to the vessels. In such cases, the colon should be mobilized promptly. On the right side of the IVC, the vessels are located so as to require clamping together almost always.

Cervical spinal cord injury without bony injury: a multicenter retrospective study of emergency and critical care centers in Japan.

BACKGROUND To demonstrate the clinical characteristics of patients with cervical cord injury (CCI) without bony injury in Japan. METHODS Retrospective review of 127 patients with CCI without bony injury treated between January 2003 and October 2005 at 11 institutions. RESULTS Prevalence of CCI without bony injury was 32.2% among all CCIs and 0.81% among all blunt traumas. Mean age was 60.4 years (range, 19-90 years), with 104 patients (82%) > or = 46 years old (older group). The major mechanism of injury among younger patients (< 46 years) was traffic injuries (39%), whereas minor falls (44%) predominated in older patients. High-energy mechanisms of injury were significantly more common for younger patients (35% versus 15%, p = 0.041). Mean injury severity score, abbreviated injury score for the head and Glasgow coma scale on admission were 17.2 +/- 4.7, 0.6 +/- 0.9, and 14.2 +/- 2.1, respectively. Incomplete CCI occurred in 88.7%. On plain cervical spine radiography, spinal canal stenosis and spondylosis or ossification of the posterior longitudinal ligament were more frequent in older patients than in younger patients (43% vs. 13%, p = 0.008; 54% vs. 17%, p = 0.002, respectively). No abnormal findings were seen in 52% of younger patients. CONCLUSION CCI without bony injury occurred more frequently in this study population than previously reported. Degenerative changes and spinal canal stenosis represent important risk factors for developing CCI without bony injury and the present results suggest that this injury may occur in younger adults during high-energy injuries in the absence of pre-existing cervical spine disease.

High D-dimer levels predict a poor outcome in patients with severe trauma, even with high fibrinogen levels on arrival : a multicenter retrospective study

ABSTRACT Elevated D-dimer level in trauma patients is associated with tissue damage severity and is an indicator of hyperfibrinolysis during the early phase of trauma. To investigate the interacting effects of fibrinogen and D-dimer levels on arrival at the emergency department for massive transfusion and mortality in severe trauma patients in a multicenter retrospective study. This study included 519 adult trauma patients with an injury severity score ≥16. Patients with ≥10 units of red cell concentrate transfusion and/or death during the first 24 h were classified as having a poor outcome. Receiver operating characteristic curve analysis for predicting poor outcome showed the optimal cut-off fibrinogen and D-dimer values to be 190 mg/dL and 38 mg/L, respectively. On the basis of these values, patients were divided into four groups: low D-dimer (<38 mg/L)/high fibrinogen (>190 mg/dL), low D-dimer (<38 mg/L)/low fibrinogen (⩽190 mg/dL), high D-dimer (≥38 mg/L)/high fibrinogen (>190 mg/dL), and high D-dimer (≥38 mg/L)/low fibrinogen (⩽190 mg/dL). The survival rate was lower in the high D-dimer/low fibrinogen group than in the other groups. Moreover, the survival rate was lower in the high D-dimer/high fibrinogen group than in the low D-dimer/high fibrinogen and low D-dimer/low fibrinogen groups. High D-dimer level on arrival is a strong predictor of early death or requirement for massive transfusion in severe trauma patients, even with high fibrinogen levels.

Can Early Aggressive Administration of Fresh Frozen Plasma Improve Outcomes in Patients with Severe Blunt Trauma?—a Report by the Japanese Association for the Surgery of Trauma

Background: This study investigated the effect of a high ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) within the first 6 and 24 h after admission on mortality in patients with severe, blunt trauma. Methods: This retrospective observational study included 189 blunt trauma patients with an Injury Severity Score (ISS) ≥16 requiring RBC transfusions within the first 24 h. Receiver operating characteristic (ROC) curve analysis was performed to calculate cut-off values of the FFP/RBC ratio for outcome. The patients were then divided into two groups according to the cut-off value. Patient survival was compared between groups using propensity score matching (PSM). Results: The area under the ROC curve was 0.57, and the FFP/RBC ratio was 1.0 at maximum sensitivity (0.57) and specificity (0.67). All patients were then divided into two groups (FFP/RBC ratio ≥1 or <1) and analyzed using PSM and inverse probability of treatment weighting (IPTW). The unadjusted hazard ratio (HR) was 0.44, and the adjusted HR was 0.29. The HR was 0.38 by PSM and 0.41 by IPTW. The survival rate was significantly higher in patients with an FFP/RBC ratio ≥1 within the first 6 h. Conclusions: Severe blunt trauma patients transfused with an FFP/RBC ratio ≥1 within the first 6 h had an HR of about 0.4. The transfusion of an FFP/RBC ratio ≥1 within the first 6 h was associated with the outcomes of blunt trauma patients with ISS ≥16 who need a transfusion within 24 h.

A case of attempted suicide from the ingestion of formalin

The ingestion of formalin causes disorders in the oral cavity, the gastrointestinal tract, liver, kidney, lung, heart, and central nervous system in the early phase of reaction. The stomach suffers the most severe damage in such cases because the formalin is in contact with the gastric mucosa longer than in the other parts of the gastrointestinal tract. Gastric ulcers and mild hemorrhaging are frequently seen. There are no reported cases of gastric perforations in Japan (n = 15), and there are only two reported cases in other countries since 1950 (n = 11). The ingestion of formalin could lead to peritonitis without perforation because of gastric wall inflammation. Cicatrical stricture of the stomach tends to be a major problem in the late phase of formalin ingestion. Similar to our case, seven of twelve reported cases of cicatrical deformity survived without operation. Therefore, a gastrectomy for the cicatrical deformity might not be always indicated if the patients are able to feed themselves sufficiently or if parenteral nutrition can be provided.

Development of Novel Criteria of the “lethal Triad” as an Indicator of Decision Making in Current Trauma Care: A Retrospective Multicenter Observational Study in Japan

Objectives: To evaluate the utility of the conventional lethal triad in current trauma care practice and to develop novel criteria as indicators of treatment strategy. Design: Retrospective observational study. Settings: Fifteen acute critical care medical centers in Japan. Patients: In total, 796 consecutive trauma patients who were admitted to emergency departments with an injury severity score of greater than or equal to 16 from January 2012 to December 2012. Interventions: None. Measurements and Main Results: All data were retrospectively collected, including laboratory data on arrival. Sensitivities to predict trauma death within 28 days of prothrombin time international normalized ratio greater than 1.50, pH less than 7.2, and body temperature less than 35°C were 15.7%, 17.5%, and 15.9%, respectively, and corresponding specificities of these were 96.4%, 96.6%, and 93.6%, respectively. The best predictors associated with hemostatic disorder and acidosis were fibrin/fibrinogen degradation product and base excess (the cutoff values were 88.8 µg/mL and –3.05 mmol/L). The optimal cutoff value of hypothermia was 36.0°C. The impact of the fibrin/fibrinogen degradation product and base excess abnormality on the outcome were approximately three- and two-folds compared with those of hypothermia. Using these variables, if the patient had a hemostatic disorder alone or a combined disorder with acidosis and hypothermia, the sensitivity and specificity were 80.7% and 66.8%. Conclusions: Because of the low sensitivity and high specificity, conventional criteria were unsuitable as prognostic indicators. Our revised criteria are assumed to be useful for predicting trauma death and have the potential to be the objective indicators for activating the damage control strategy in early trauma care.