Toyomu Ugawa

Characteristics and costs of ditch-related injuries: a report from a single emergency center in Okayama

This study was designed to identify the incidence, injury patterns, and financial burden of ditch‐related injuries to provide a reference for establishing guidelines on the prevention of such injuries.

Recurrent apnea in an infant with pertussis due to household transmission

Bordetella pertussis causes life‐threatening apnea in infants. Lymphocytosis is an important clue for diagnosis and for determining the severity of pertussis. Antibiotics do not shorten or ameliorate the disease and only decrease the risk of transmission. Antepartum maternal immunization is important for preventing pertussis in infants.

A case of cricothyroidotomy for facial trauma in a patient taking antiplatelet agents after a simple ground-level fall

Highlights • We describe a case of facial trauma in which cricothyroidotomy was required after simple ground-level fall.• Mandibular condyle fractures can cause emergency airway in an elderly patient who is taking antiplatelet agents even after simple ground-level fall.• Prophylactic intubation should be considered prior to transfer or deterioration in such a trauma patient.

Soft tissue hematoma of the neck due to thyroid rupture with unusual mechanism.

Highlights • Massive bleeding from the thyroid without direct neck trauma rarely causes airway compromise.• Physicians should regard possible thyroid gland rupture in patients with swelling of the neck or acute respiratory failure after direct/indirect trauma to the neck.• Airway management is the most important consideration in such patients with thyroid injury.

Superior ophthalmic vein thrombosis associated with severe facial trauma: a case report.

IntroductionSuperior ophthalmic vein thrombosis is a rare entity, but is associated with significant morbidities. We describe a case in which superior ophthalmic vein thrombosis occurred shortly after severe facial trauma.Case presentationA 77-year-old Japanese man was transferred to our tertiary hospital after a motor vehicle accident. Le Fort III facial bone fractures and a minor cerebral contusion were detected. Follow-up computed tomography scans detected dilatation of his left superior ophthalmic vein on day 3 and thrombosis on day 12; however, no causative carotid cavernous fistula was observed. As he did not present with any symptoms other than slight conjunctival congestion, a conservative management strategy was adopted along with anticoagulant therapy against deep venous thrombosis. The superior ophthalmic vein thrombosis resolved spontaneously and the conjunctival congestion also improved.ConclusionsSuperior ophthalmic vein thrombosis should be taken into consideration and managed properly after severe facial injuries, and further investigation of its cause is necessary to prevent morbidities.

Septic shock due to Aeromonas hydrophila bacteremia in a patient with alcoholic liver cirrhosis: a case report.

IntroductionAeromonas hydrophila sometimes causes bacteremia, which can be fatal in compromised patients, such as those with liver cirrhosis. We present a case of septic shock due to Aeromonas hydrophila bacteremia in a patient with liver cirrhosis, which was successfully treated with rapid resuscitation and critical care.Case presentationA 71-year-old Japanese man with liver cirrhosis was transported to our emergency center by ambulance after presenting with gait difficulties and fever. On arrival, he exhibited shock and severe lactic acidosis, which was suggestive of sepsis, and was immediately resuscitated and administered empiric antibiotic therapy. He also displayed catecholamine-resistant hypotension, which was successfully treated with critical care including supportive therapies, such as polymyxin B hemoperfusion and cytokine-absorbing hemofiltration. Aeromonas hydrophila was detected in his initial blood cultures.ConclusionsAeromonas septicemia should be considered in patients with alcoholic liver cirrhosis who have profound shock. In addition to goal-directed therapy and the prompt administration of empiric antibiotic therapy, aggressive critical care involving multiple supportive therapies can save such patients.

AN69ST membranes adsorb nafamostat mesylate and affect the management of anticoagulant therapy: a retrospective study

BackgroundIn Japan, nafamostat mesylate (NM) is frequently used as an anticoagulant during continuous renal replacement therapy (CRRT). The dialyzer membrane AN69ST has been reported to adsorb NM and affect the management of anticoagulant therapy. However, the adsorbed amount has not yet been quantitatively assessed. Therefore, in this study, we evaluated the pre- and post-hemofilter prolongation of the activated clotting time (ACT) in patients with AN69ST and PS membranes. We also measured the adsorption of NM in three types of CRRT membranes using an experimental model.MethodsIn a study of patients who underwent CRRT using AN69ST or PS membranes in 2015 at the Advanced Emergency and Critical Care Center, Okayama University Hospital, pre- and post-hemofilter ACT measurements were extracted retrospectively, and the difference was calculated. In addition, AN69ST (sepXiris100), PS (HEMOFEEL SHG-1.0), and PMMA membranes (HEMOFEEL CH-1.0N) were used in an in vitro model of a dialysis circuit, and the concentrations of NM were measured in pre- and post-hemofilter membranes and filtrates.ResultsThe ACT difference was significantly lower in the group using AN69ST membranes (p < 0.01). In the in vitro model (n = 4) with adsorption and filtration, the post-hemofilter and filtrate concentrations of NM in AN69ST membranes were significantly lower than those in the PS and PMMA membranes (p < 0.01). The NM adsorption clearance of the AN69ST membrane was significantly higher than that of the PS and PMMA membranes.ConclusionsThe AN69ST membrane had higher NM adsorption than the PS and PMMA membranes. This may have resulted in the lower ACT difference in patients undergoing CRRT using the AN69ST membrane than in patients undergoing CRRT using PS or PMMA membranes.

Three cases of heparin-induced thrombocytopenia associated with polytrauma

We present three cases in which patients that had suffered polytrauma developed heparin‐induced thrombocytopenia after the start of heparin treatment for thrombosis. All three patients had high injury severity scores and required major surgery. They all started receiving unfractionated heparin for deep venous thrombosis with or without an asymptomatic pulmonary embolism. The patients were clinically diagnosed with heparin‐induced thrombocytopenia after their platelet counts fell or exhibited a delayed recovery.

Ditch-related falls: Need for preventive educational campaigns

Dear Editor, We previously reported on 13 ditch-related injury cases in Okayama in Acute Medicine and Surgery. Since then we have focused on preventive educational campaigns through mass media in our community. However, tragic ditchrelated falls involving children have still occurred. Here we describe three subsequent pediatric cases related to ditch falls. A 3-year-old boy presented after falling into a ditch with water at a depth of 1 m. He was rescued by his mother after being swept downstream for 1 m. His level of consciousness diminished soon after rescue. However, he showed neither major trauma nor neurological sequelae. A 3-year-old boy was transported to our hospital with cardiopulmonary arrest after drowning in a ditch with water at a depth of 110 cm. He was found 1 h after he went missing. He was hypothermic (34.1°C) and extracorporeal cardiopulmonary resuscitation was performed. Unfortunately, he died of multiple organ failure 8 h later. He had no major trauma. A 4-year-old boy was transported to our hospital with cardiopulmonary arrest after drowning in a ditch with water at a depth of 90 cm. He was found 20 min after he went missing. Extracorporeal cardiopulmonary resuscitation was performed. He was weaned off extracorporeal membrane oxygenation on day 6. Unfortunately, he died of brain edema on day 33. Our previous report detailed the characteristics of severe ditch-related injury cases, which included being middleaged, bicycles, night-time incidents, and late presentation in rural areas. We suggested these characteristics as targets of preventive educational campaigns. Table 1 shows the characteristics of the three pediatric cases described in this letter. It indicates the devastating consequences of unsupervised toddlers falling into ditches and drowning in broad daylight in urban areas. Considering that unintentional accidents are the leading cause of pediatric death in Japan, urgent action to prevent ditch-related falls is desperately needed. According to an official document released by the Okayama city council, the city contains 4,000 km of irrigation ditches. As the total ditch length in Japan amounts to 400,000 km, Okayama city should act to prevent the significant risk of falling and drowning. In our previous report, we suggested considerable local government intervention. However, as the scale of the problem is immense because of the area involved, the government response will need to be assisted with educational campaigns. Therefore, preventive educational action should be conducted across multiple fields, not only in public administration but also in academic communities to help prevent pediatric death through ditch falls. We have been interviewed about ditch-related injuries by a city councilman, and have reported on ditch-related falls to pediatricians in our community through conference presentations. It is desirable that educational campaigns aimed at children involve educational institutions. Informative posters, with the help of primary care clinics and public transportation facilities, would be a helpful tool in further educational campaigns to increase the range of citizens reached. Finally, we appeal for the importance of additional surveys in relation to ditch-related falls throughout the whole of Okayama Prefecture.

Tetanus in a 19-year-old Japanese Woman

A 19-year-old Japanese woman presented with a suddenonset of difficulty in opening her mouth (Picture A). Trismus and cervicofacial involuntary movements in the patient were easily triggered by stimulation. Although there was no recent history of trauma, minor skin disorders were seen on her foot (Picture B). The patient’s medical history revealed that she had never been vaccinated with tetanus toxoid. We diagnosed the patient with tetanus and administered tetanus immune globulin (5,000 units), toxoid vaccination, and intravenous penicillin G (2,400 million units per day). The patient’s neuromuscular manifestations gradually improved and she was discharged on day 10. Tetanus is a fatal disease in developing countries where vaccination is unavailable. In Japan, with the introduction of preventive immunization in 1968, the incidence of tetanus has dramatically declined. Presently, almost all Japanese cases are in patients over forty years of age who had been born before the implementation of routine vaccination; teenagers are scarcely reported as having this disease (1). For cases in which tetanus is suspected, urgent treatment is necessary (2).