Yasuhiko Tsukada

Repeated embolization of intercostal arteries after blunt chest injury

To deal with an arterial bleeding from the chest wall after a blunt chest injury, embolization of the bleeding arteries can be a valuable therapeutic option, which is less invasive than a thoracotomy. However, its results are variable, being highly operator-dependent. In the present case, we performed successful emergency embolization of the 4th and 5th intercostal arteries for persistent hemorrhage following blunt trauma to the chest. Several days after the first embolization, secondary embolization was required for treating a pseudoaneurysm that was formed in the 5th intercostal artery. Although the mechanisms underlying pseudoaneurysm formation are not clearly understood, its rupture is potentially fatal. Therefore, it is essential to carefully follow-up patients who experience blunt chest injury to avoid this serious complication.

Establishment and implementation of an effective rule for the interpretation of computed tomography scans by emergency physicians in blunt trauma

IntroductionComputed tomography (CT) can detect subtle organ injury and is applicable to many body regions. However, its interpretation requires significant skill. In our hospital, emergency physicians (EPs) must interpret emergency CT scans and formulate a plan for managing most trauma cases. CT misinterpretation should be avoided, but we were initially unable to completely accomplish this. In this study, we proposed and implemented a precautionary rule for our EPs to prevent misinterpretation of CT scans in blunt trauma cases.MethodsWe established a simple precautionary rule, which advises EPs to interpret CT scans with particular care when a complicated injury is suspected per the following criteria: 1) unstable physiological condition; 2) suspicion of injuries in multiple regions of the body (e.g., brain injury plus abdominal injury); 3) high energy injury mechanism; and 4) requirement for rapid movement to other rooms for invasive treatment. If a patient meets at least one of these criteria, the EP should exercise the precautions laid out in our newly established rule when interpreting the CT scan. Additionally, our rule specifies that the EP should request real-time interpretation by a radiologist in difficult cases. We compared the accuracy of EPs’ interpretations and resulting patient outcomes in blunt trauma cases before (January 2011, June 2012) and after (July 2012, January 2013) introduction of the rule to evaluate its efficacy.ResultsBefore the rule’s introduction, emergency CT was performed 1606 times for 365 patients. We identified 44 cases (2.7%) of minor misinterpretation and 40 (2.5%) of major misinterpretation. After introduction, CT was performed 820 times for 177 patients. We identified 10 cases (1.2%) of minor misinterpretation and two (0.2%) of major misinterpretation. Real-time support by a radiologist was requested 104 times (12.7% of all cases) and was effective in preventing misinterpretation in every case. Our rule decreased both minor and major misinterpretations in a statistically significant manner. In particular, it conspicuously decreased major misinterpretations.ConclusionOur rule was easy to practice and effective in preventing EPs from missing major organ injuries. We would like to propose further large-scale multi-center trials to corroborate these results.

Patient questionnaire following closure of tracheotomy fistula: percutaneous vs. surgical approaches

BackgroundTracheotomy is an indispensable component in intensive care management. Doctors in charge of the intensive care unit (ICU) usually decide whether tracheotomy should be performed. However, long-term follow-up of a closed fistula by these doctors is rarely continued in most cases. Doctors in charge of the ICU should be interested in the long-term prognosis of tracheotomy. The purpose of this study was to evaluate whether different tracheotomy procedures affect the long-term outcome of a closed tracheal fistula.MethodsWe mailed questionnaires to patients undergoing tracheotomy in Fukushima Medical University Hospital between January 2008 and December 2010. Questions concerned problems related to perception, laryngeal function, and the appearance of a closed fistula. Patients were classified into percutaneous tracheotomy (PT) group and surgical tracheotomy (ST) group. We evaluated the statistical significance of differences in the frequency and degree of each problem between the two groups. A door-to-door objective evaluation using the original scoring system was then performed for patients who replied to the mailed questionnaire. We evaluated the percentage of patients with high scores as well as the mean scores for problems with function and appearance.ResultsWe received completed questionnaires from 28/40 patients in the PT group and 35/55 patients in the ST group. There were no significant differences in age, mean hospital stay, or APACHE II score between the groups. Regarding problems with appearance, the outcomes of PT were significantly better than those of ST with respect to self-evaluation (p = 0.04) and the frequency (p = 0.03) and degree (p = 0.02) of scar unevenness according to door-to-door evaluation. However, there were no significant differences in the frequency or degree of self-evaluation in problems with perception and function between the two groups. There were no significant differences in the frequency or degree of door-to-door evaluation of problems with function.ConclusionsThis study shows that PT might be superior to ST with respect to problems with long-term appearance. Continuous follow-up of closed tracheal fistulas can help assure that patients recovering from a critical condition experience a better return to their former lives. A systematic follow-up of post-critical-care patients is required.

Acute renal failure caused by severe coagulopathy induced by the interaction between warfarin potassium and levofloxacin: a case report

To the Editor: A 30-year-old man took warfarin potassium (4 mg/day) for several years because of idiopathic dilated cardiomyopathy (ejection fraction was 48 %, and no arrhythmia was observed). His medical regimen included aspirin (100 mg/day), digoxin (0.25 mg/day), pimobendan (20 mg/day), and atenolol (50 mg/day); glimepiride (4 mg/day), voglibose (2.7 mg/day), and allopurinol (900 mg/day) (for diabetes mellitus and hyperuricemia); and milnacipran hydrochloride (25 mg/day), fluvoxamine maleate (200 mg/day), risperidone (2 mg/day), and sodium valproate (800 mg/day) (for Asperger’s syndrome). Despite the long-term use of these medicines, neither renal disorders nor bleeding tendencies were observed [prothrombin time (PT)-international normalized ratio (INR) (PT-INR) was controlled around 1.5]. The patient presented to the emergency room with hematuria. Laboratory analyses indicated elevated white blood cell counts (20,500 cells/m) and C-reactive protein levels (4.5 mg/dl), but no anemia. We suspected urinary tract infection; therefore, levofloxacin (900 mg/day) was prescribed. After 6 days, the patient was brought to the emergency room because of hypovolemic shock resulting from nasal hemorrhage (Hb 3.7 mg/dl, Hct 10.9 %). Prothrombin time (PT) could not be determined. Acute renal failure (ARF) was suspected because of elevated blood urea nitrogen (100 mg/dl), creatinine (6.2 mg/dl), and serum potassium (6.2 mmol/l) levels. Severe hematuria with a distinct blood clot was observed. Warfarin and aspirin were discontinued; vitamin K (20 mg) was administered. Under strict observation for volume overload, Ringer’s solution and washed red cells were administered. Sufficient spontaneous urine production was maintained. Renal function recovered without hemodialysis. The hypovolemic shock caused by nasal bleeding and severe hematuria resulted in prerenal ARF; the hematoma that obstructed the urinary tract resulted in postrenal ARF. We believed both preand postrenal ARF were present. The patient’s course of PTINR and creatinine values is shown in Fig. 1. The patient had been taking warfarin for 3 years. Bleeding improved with vitamin K; therefore, the cause of coagulopathy was thought to be reinforced by the effects of warfarin. Several drugs interact with warfarin [1]. We suspected that valproate, allopurinol, and levofloxacin could interact with warfarin. ARF may have caused elevated plasma valproate and allopurinol concentrations, which could have then interacted with warfarin. However, valproate and allopurinol previously had been taken routinely, without bleeding tendencies. Thus, the newly prescribed levofloxacin was mainly responsible for this coagulopathy. Ofloxacin suppress the propagation of vitamin K-producing enteric bacteria, and thus the effects of warfarin would be enhanced. Also, warfarin and ofloxacin competitively bind with protein. Thus, the free effect of warfarin increases with the use of ofloxacin [2]. Levofloxacin and ofloxacin are both C. Nemoto (&) Y. Ikegami J. Shimada Y. Tsukada Y. Abe C. Tase Department of Critical Care and Emergency Medicine, Fukushima Medical University, 1-Hikarigaoka, Fukushima 960-1295, Japan e-mail: nemo@fmu.ac.jp

EARLY STAGE RESPONSES OF INTENSIVE CARE UNITS DURING MAJOR DISASTERS: FROM THE EXPERIENCES OF THE GREAT EAST JAPAN EARTHQUAKE

The present study investigated the role of intensive care units (ICU) during disasters, including the responses of our ICU following the Great East Japan Earthquake on March 11, 2011. Our ICU comprises 8 beds for postoperative inpatients and those with rapidly deteriorating conditions; 20 beds in an emergency unit for critically ill patients; and 17 beds for neonates. It is important to secure empty beds when a major disaster occurs, as was the case after the Great Hanshin Earthquake, due to the resulting large numbers of trauma patients. Therefore, each ICU section cooperated to ensure sufficient space for admissions following the Great East Japan Earthquake. However, unlike the Great Hanshin Earthquake, securing beds was ultimately unnecessary due to the nature of the recent disaster, which also consisted of a subsequent tsunami and nuclear accident. Therefore, air quality monitoring was required on this occasion due to the risk of environmental radioactive pollution from the nuclear disaster causing problems with artificial respiration management involving atmospheric air. The variability in damage arising during different disasters thus requires a flexible response from ICUs that handle seriously ill patients.

Activation Intervals for a Helicopter Emergency Medical Service in Japan

INTRODUCTION Prehospital time is crucial for treating acute disease; therefore, it is important to activate helicopter emergency medical services (HEMS) promptly. We investigated the differences in the activation intervals (the time elapsed from receiving the emergency call to the time of HEMS request) under various conditions to evaluate the current status of HEMS-related prehospital triage in Japan. METHODS We retrospectively investigated activation intervals under exogenous (trauma, n = 553; intoxication, n = 56; and burns, n = 32) and endogenous conditions (acute coronary syndrome [ACS], n = 47; and stroke, n = 173) between January 31, 2008, and January 31, 2012, by reviewing flight records. RESULTS Activation intervals were trauma (14.3 ± 11.5 min), intoxication (10.3 ± 8.6 min), burns (15.0 ± 13.1 min), ACS (17.9 ± 14.6 min), and stroke (19.1 ± 13.1 min). One-way analysis of variance showed a significant difference between exogenous and endogenous groups (P < .001). Post-hoc analysis using Tukeys honestly significant difference test showed significant differences between ACS and intoxication (P < .05), stroke and intoxication (P < .001), and stroke and trauma (P < .001). CONCLUSIONS Endogenous conditions had longer activation intervals, which may reflect a lack of mechanisms assessing their severity. We are considering developing new triage criteria for dispatchers.

Delayed shock after minor blunt trauma due to myocarditis caused by occult giant pheochromocytoma.

Pheochromocytoma, a tumor originating from the adrenal glands, has a classical triad of catecholamine-induced headache, palpitation and diaphoresis. Approximately 10% of pheochromocytomas develop asymptomatically and are revealed incidentally in 0.35–4.6% of patients who undergo abdominal computed tomography (CT). There are reported cases of catecholamine crisis induced by spontaneous rupture or hemorrhage into the tumor. Some occult pheochromocytomas are detected by X-ray after routine trauma examination. However, cases with severe myocarditis induced by blunt trauma are extremely rare. The prognosis of patients with systemic circulatory failure with organ disorder and severe pulmonary edema is usually extremely poor. We report a case of delayed shock and fulminant myocarditis after minor blunt trauma caused by the compression of an occult giant pheochromocytoma.

Cardiac tamponade after extracorporeal cardiopulmonary resuscitation

Dear Editor, Cardiac tamponade related with cardiopulmonary resuscitation (CPR) has been reported. Here, we describe our experience with cardiac tamponade after extracorporeal cardiopulmonary resuscitation. A 62-year-old man presented with post-epidural abscess. Soon after the iopamidol injection (100 mL) for cranial contrast computed tomography, the patient complained of a general heat sensation and then went into cardiopulmonary arrest due to iopamidol-related anaphylaxis. Cardiopulmonary resuscitation was immediately carried out, and spontaneous circulation returned 23 min later. However, a state of pulseless electrical activity occurred 7 min after repeated resuscitation. Therefore, we decided to introduce venoarterial extracorporeal membrane oxygenation (ECMO); the cannulation was carried out from the right side of the femoral artery and vein. Satisfactory blood pressure was achieved 55 min after the cardiopulmonary arrest. Echocardiography did not indicate a cardiogenic cause or pericardial effusion at this time (Fig. 1A). The ECMO flow was approximately 2 L/min, systolic blood pressure was maintained at approximately 80–100 mmHg, and heart rate was 80–90 b.p.m. Central venous pressure (CVP) was 9–11 mmHg. Heparin sodium was administered to maintain the activated clotting time at approximately 150 s. Ten hours later, blood pressure had gradually decreased to 50 mmHg, and CVP had increased remarkably to 35 mmHg. Echocardiography was carried out again, and pericardial effusion was observed (Fig. 1B). Percutaneous pericardial drainage was immediately carried out, following which CVP and blood pressure returned to 9–11 mmHg and 80–100 mmHg, respectively. The hemoglobin and PaO2 levels of the collected bloody pericardial effusion (450 mL) were 11 g/dL and 24.8 mmHg, respectively, indicating venous blood. The patient was weaned from the ECMO on day 3, and the drainage tube was removed on day 5. Positive airway ventilation was required for flail chest resulting from multiple rib fractures (right 4th to 8th ribs) that occurred during CPR. During hospitalization, the patient developed pneumonia, for which he was treated with antibiotics, and ultimately discharged from our hospital 83 days later without any complications other than his pre-existing problems. Cardiac tamponade is one of the most undesired complications of CPR and can also occur as a result of extracorporeal cardiopulmonary resuscitation. In our case, there were a couple of possible causes of cardiac tamponade: cardiovascular perforation by the fractured ribs during cardiac massage, or damage to the cardiac wall by the guide wire or venous cannula during the introduction of ECMO. However, these causes would likely be apparent during echocardiography, which was carried out soon after the cardiac tamponade occurred. Therefore, we think that the bleeding was very trivial initially but was accelerated by the anticoagulant therapy for ECMO, causing delayed cardiac tamponade, because antiplatelet therapy has also been indicated as a cause of cardiac tamponade after CPR. The progression of cardiac tamponade escaped our notice at the early stage because circulation was maintained with ECMO; it became apparent only with circulatory collapse. We recommend that rare complications such as cardiac

Usefulness of initial diagnostic tests carried out in the emergency department for blunt trauma

To evaluate the usefulness of the initial diagnostic tests carried out in blunt trauma patients in our emergency department.

Investigation of final destination hospitals for patients in helicopter emergency medical services (doctor-helicopter) in Fukushima Prefecture

PurposeIn using an emergency medical service helicopter with an emergency medicine doctor on board (doctor–helicopter), transporting all patients to the University Hospital (base hospital for the helicopter) could cause a chronic bed shortage at the University Hospital. It is also disadvantageous for patients from distant areas. We investigated whether appropriate hospital selections are being carried out in Fukushima Prefecture.MethodsThe subjects of the study were patients who were transported by doctor–helicopter since the services started. We investigated the medical conditions of patients at emergency scenes, whether they were transported to a hospital inside or outside the region, the means of transportation, and the final destination hospital.ResultsThere were 450 flights, of which 295 were to emergency scenes, involving 307 patients. The majority were trauma patients (191 patients, 62.2%). The final destination hospital was the University Hospital for 104 patients (33.9%); 99 patients (30.3%) were transported to three emergency and critical care medical centers (ECCMCs) in other regions. Most patients were transported to appropriate hospitals in the respective regions. The means of transportation from the emergency scene was by doctor–helicopter in the largest number of cases (223 patients, 72.6%), and the final destination hospital was ECCMCs in 81.6% of cases.ConclusionPatients from emergency scenes are transported by doctor–helicopter to appropriate hospitals in the region, and hospitals in each region are cooperating with the doctor–helicopter operations.