Tomokazu Motomura

Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one of the ultimately invasive procedures for managing a noncompressive torso injury. Since it is less invasive than resuscitative open aortic cross-clamping, its clinical application is expected. METHODS We retrospectively evaluated the safety and clinical feasibility of REBOA (intra-aortic occlusion balloon, MERA, Tokyo, Japan) using the Seldinger technique to control severe hemorrhage. Of 5,230 patients admitted to our trauma center in Japan from 2007 to 2013, we included 24 who underwent REBOA primarily. The indications for REBOA were a pelvic ring fracture or hemoperitoneum with hemodynamically instability and impending cardiac arrest. Emergency hemostasis was performed during REBOA in all patients. RESULTS All 24 patients had a blunt injury, the median age was 59 (interquartile range, 41–71 years), the median Injury Severity Score (ISS) was 47 (interquartile range, 37–52), the 30-day survival rate was 29.2% (n = 7), and the median probability survival rate was 12.5%. Indications for REBOA were hemoperitoneum and pelvic ring fracture in 15 cases and overlap in 8 cases. In 10 cases of death, the balloon could not be deflated in 5 cases. In 19 cases in which the balloon was deflated, the median duration of aortic occlusion was shorter in survivors than in deaths (21 minutes vs. 35 minutes, p = 0.05). The mean systolic blood pressure was significantly increased by REBOA (from 53.1 [21] mm Hg to 98.0 [26.6] mm Hg, p < 0.01). There were three cases with complications (12.5%), one external iliac artery injury and two lower limb ischemias in which lower limb amputation was necessary in all cases. Acute kidney injury developed in all three cases, but failure was not persistent. CONCLUSION REBOA seems to be feasible for trauma resuscitation and may improve survivorship. However, the serious complication of lower limb ischemia warrants more research on its safety. LEVEL OF EVIDENCE Therapeutic/care management, level V.

Effect of admission glasgow coma scale motor score on neurological outcome in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia

BACKGROUND Because the initial (on admission) Glasgow Coma Scale (GCS) examination has not been fully evaluated in comatose survivors of cardiac arrest (CA) who receive therapeutic hypothermia (TH), the aim of the present study was to determine any association between the admission GCS motor score and neurologic outcomes in patients with out-of-hospital CA who receive TH. METHODSANDRESULTS In the J-PULSE-HYPO study registry, patients with bystander-witnessed CA were eligible for inclusion. Patients were divided into 3 groups based on GCS motor score (1, 2-3, and 4-5) to assess various effects on neurologic outcome. Univariate and multivariate analyses were performed to identify independent predictors of good neurologic outcome at 90 days. Of 452 patients, 302 were enrolled. There was a significant difference among the 3 patient groups with regard to neurologic outcome at 90 days in the univariate analysis. Multiple logistic regression analyses showed that the GCS motor score on admission, age >65 years, bystander cardiopulmonary resuscitation, the time from collapse to return of spontaneous circulation, and pupil size <4 mm were independent predictors of a good neurologic outcome at 90 days in cases of CA (GCS motor score, 4-5: odds ratio, 8.18; 95% confidence interval: 1.90-60.28; P<0.01). CONCLUSIONS GCS motor score is an independent predictor of good neurologic outcome at 90 days in patients sustaining out-of-hospital CA who receive TH.

Serious injury prediction algorithm based on large-scale data and under-triage control

The present study was undertaken to construct an algorithm for an advanced automatic collision notification system based on national traffic accident data compiled by Japanese police. While US research into the development of a serious-injury prediction algorithm is based on a logistic regression algorithm using the National Automotive Sampling System/Crashworthiness Data System, the present injury prediction algorithm was based on comprehensive police data covering all accidents that occurred across Japan. The particular focus of this research is to improve the rescue of injured vehicle occupants in traffic accidents, and the present algorithm assumes the use of an onboard event data recorder data from which risk factors such as pseudo delta-V, vehicle impact location, seatbelt wearing or non-wearing, involvement in a single impact or multiple impact crash and the occupants age can be derived. As a result, a simple and handy algorithm suited for onboard vehicle installation was constructed from a sample of half of the available police data. The other half of the police data was applied to the validation testing of this new algorithm using receiver operating characteristic analysis. An additional validation was conducted using in-depth investigation of accident injuries in collaboration with prospective host emergency care institutes. The validated algorithm, named the TOYOTA-Nihon University algorithm, proved to be as useful as the US URGENCY and other existing algorithms. Furthermore, an under-triage control analysis found that the present algorithm could achieve an under-triage rate of less than 10% by setting a threshold of 8.3%.

Development of an Educational Program for the Helicopter Emergency Medical Services in Japan

INTRODUCTION The Japanese helicopter emergency medical service (HEMS) system provides advanced prehospital treatment at the scene. The education of the dispatched HEMS physicians is important for guaranteeing the quality of medical and safety management, but there is no nationally established training program. This study aimed to determine the validity of the HEMS educational program developed by our team. METHODS A 3-step educational program was designed for HEMS trainees: step 1, 20 HEMS missions as an observer; step 2, 80 missions of on-the-job training; and step 3, certifying examination conducted by a supervisor. As an evaluation standard, scene time, defined as time from landing at the scene to taking off for a hospital, was determined retrospectively. RESULTS For trainees, scene time was significantly longer (16.3 ± 5.4 min, 95% CI 15.5-17.1) than for experts (doctors who completed >200 HEMS missions; 15.2 ± 6.7 min, 95% CI 14.7-15.8; P = 0.040) but was significantly shorter than for doctors trained before establishment of the HEMS program (17.5 ± 7.0 min, 95% CI 16.9-18.2; P = 0.030). In cases of trauma or intrinsic disease, there was no significant difference in scene time between trainees (17.4 ± 5.6 min and 14.9 ± 4.8 min, respectively) and experts (16.4 ± 7.8 min and 14.2 ± 5.5 min, respectively). CONCLUSION The finding that scene time was shortened for program trainees demonstrates the validity of our HEMS educational program. The quality of HEMS missions will be better ensured through this educational system.

Dispatch of Helicopter Emergency Medical Services Via Advanced Automatic Collision Notification.

BACKGROUND Advanced automatic collision notification (AACN) is a system for predicting occupant injury from collision information. If the helicopter emergency medical services (HEMS) physician can be alerted by AACN, it may be possible to reduce the time to patient contact. OBJECTIVE The purpose of this study was to validate the feasibility of early HEMS dispatch via AACN. METHODS A full-scale validation study was conducted. A car equipped with AACN was made to collide with a wall. Immediately after the collision, the HEMS was alerted directly by the operation center, which received the information from AACN. Elapsed times were recorded and compared with those inferred from the normal, real-world HEMS emergency request process. RESULTS AACN information was sent to the operation center only 7 s after the collision; the HEMS was dispatched after 3 min. The helicopter landed at the temporary helipad 18 min later. Finally, medical intervention was started 21 min after the collision. Without AACN, it was estimated that the HEMS would be requested 14 min after the collision by fire department personnel. The start of treatment was estimated to be at 32 min, which was 11 min later than that associated with the use of AACN. CONCLUSIONS The dispatch of the HEMS using the AACN can shorten the start time of treatment for patients in motor vehicle collisions. This study demonstrated that it is feasible to automatically alert and activate the HEMS via AACN.

The Pedicled Omental Flap Technique for Treating Extensive Defects or Soft-Tissue Infection of the Pelvic Area: A Report of 2 Cases

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

The Mission to Control Plural Doctor Helicopters at Fukushima Medical University Hospital for the 2011 of the Great East Japan Earthquake

2011 年 3 月 11 日,筆者は日本医大千葉北総ドク ターヘリにて市川市で発生した交通外傷症例対応に従 事していた.都内医療機関への搬送を決定し,傷病者 のヘリ移送を開始した 14 時 46 分,現場震度 5弱の地 震が発生した.臨時ヘリポートとして使用した河川敷 は波打ち,搬送予定であった医療機関は停電に伴いエ レベーターが使用不可で搬入不能となったため,われ われは北総病院へ傷病者とともに帰還することを決定 した. 帰還途中の上空から,千葉県内各所からの黒煙およ び学校グラウンドに避難する生徒らを認めた.県内各 所の災害事象が想定され無線にて当院へ傷病者状況を 伝えるとともに,DMAT出動の可能性が高いことを 伝えた. 15 時 15 分当院帰還後,院内の災害対策本部立ち上 げに従事するとともに,メディアなどより震源地や震 度などの情報と,岩手,宮城,福島県で津波被害が甚 大であることを把握した. 県内で差し迫ったドクターヘリの需要なく,県と相 談を経て北総DMATを,DMAT参集拠点病院であ る福島県立医大へ派遣することを決定した.日中のド クターヘリミッション終了後の 18 時 35 分離陸,19 時 55 分福島県立医科大学に到着した.福島県立医大 のDMAT本部立ち上げに従事後,ドクターヘリ統制 本部の立ち上げを開始した.