Yoshimitsu Izawa

Nonoperative management of hemodynamically unstable abdominal trauma patients with angioembolization and resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND Many hemodynamically stable patients with blunt abdominal solid organ injuries are successfully managed nonoperatively, while unstable patients often require urgent laparotomy. Recently, therapeutic angioembolization has been used in the treatment of intra-abdominal hemorrhage in hemodynamically unstable patients. We undertook this study to review a series of hemodynamically unstable patients with abdominal solid organ injuries managed nonoperatively with angioembolization and resuscitative endovascular balloon occlusion of the aorta. METHODS The institutional review board approved this study. All patients were appropriately resuscitated with transfusions, and angiography was performed after computed tomography. Resuscitative endovascular balloon occlusion of the aorta was performed before computed tomography in all patients. RESULTS Seven patients underwent resuscitative endovascular balloon occlusion of the aorta following severe blunt abdominal trauma. The 28-day survival rate was 86% (6 of 7). There were no complications related to the procedure. CONCLUSION We describe the first clinical series of hemodynamically unstable patients with abdominal solid organ injury treated nonoperatively with angioembolization and resuscitative endovascular balloon occlusion of the aorta. Survival rate was 86%, supporting the need for further study of this modality as an adjunct to the nonoperative management of patients with severe traumatic injuries. LEVEL OF EVIDENCE Therapeutic study, level V.

Predicting the need for massive transfusion in trauma patients: the Traumatic Bleeding Severity Score.

BACKGROUND The ability to easily predict the need for massive transfusion may improve the process of care, allowing early mobilization of resources. There are currently no clear criteria to activate massive transfusion in severely injured trauma patients. The aims of this study were to create a scoring system to predict the need for massive transfusion and then to validate this scoring system. METHODS We reviewed the records of 119 severely injured trauma patients and identified massive transfusion predictors using statistical methods. Each predictor was converted into a simple score based on the odds ratio in a multivariate logistic regression analysis. The Traumatic Bleeding Severity Score (TBSS) was defined as the sum of the component scores. The predictive value of the TBSS for massive transfusion was then validated, using data from 113 severely injured trauma patients. Receiver operating characteristic curve analysis was performed to compare the results of TBSS with the Trauma-Associated Severe Hemorrhage score and the Assessment of Blood Consumption score. RESULTS In the development phase, five predictors of massive transfusion were identified, including age, systolic blood pressure, the Focused Assessment with Sonography for Trauma scan, severity of pelvic fracture, and lactate level. The maximum TBSS is 57 points. In the validation study, the average TBSS in patients who received massive transfusion was significantly greater (24.2 [6.7]) than the score of patients who did not (6.2 [4.7]) (p < 0.01). The area under the receiver operating characteristic curve, sensitivity, and specificity for a TBSS greater than 15 points was 0.985 (significantly higher than the other scoring systems evaluated at 0.892 and 0.813, respectively), 97.4%, and 96.2%, respectively. CONCLUSION The TBSS is simple to calculate using an available iOS application and is accurate in predicting the need for massive transfusion. Additional multicenter studies are needed to further validate this scoring system and further assess its utility. LEVEL OF EVIDENCE Prognostic study, level III.

Takotsubo Cardiomyopathy as a Delayed Complication with a Herbicide Containing Glufosinate Ammonium in a Suicide Attempt: A Case Report

Background. Glufosinate ammonium has a famous delayed complication as respiratory failure, however, delayed cardiogenic complication is not well known. Objectives. The aim of this study is to report a takotsubo cardiomyopathy as a delayed complication of glufosinate ammonium for suicide attempt. Case Report. A 75-year-old woman ingested about 90 mL of Basta, herbicide for suicide attempt at arousal during sleep. She came to our hospital at twelve hours after ingesting. She was admitted to our hospital for fear of delayed respiratory failure. Actually, she felt down to respiratory failure, needing a ventilator with intubation at 20 hours after ingesting. Procedure around respiratory management had smoothly done with no delay. Her vital status had been stable, however, she felt down to circulatory failure and diagnosed as Takotsubo cardiomyopathy at about 41 hours after ingestion. There was no trigger activities or events to evoke mental and physical stresses. Conclusion. We could successfully manage takotsubo cardiomyopathy resulted in circulatory failure in a patient with glufosinate poisoning for suicide attempt. Takotsubo cardiomyopathy should be taken into consideration if circulatory failure is observed for unexplained reasons.

Analysis of risk classification for massive transfusion in severe trauma using the gray zone approach.

BACKGROUND The Traumatic Bleeding Severity Score (TBSS) was developed to predict the need for massive transfusion (MT). The aim of this study is evaluation of clinical thresholds for activation of a MT protocol using the gray zone approach based on TBSS. METHODS This is a single-center retrospective study of trauma patients, admitted from 2010 to 2013. The TBSS on admission was calculated, and the accuracy of predicting MT was analyzed using area under the receiver operating characteristic curve. Risk classification for MT was made using sensitivity/specificity. The gray zone (indeterminate risk) was defined from a sensitivity of 95% to a specificity of 95%, patients were separated into MT and non-MT groups, and their clinical characteristics were compared. RESULTS A total of 264 patients were enrolled, with an area under the TBSS curve of 0.967 (95% confidence interval, 0.94-0.99). A TBSS of 10 points or less resulted in a sensitivity of 96.5% with 146 patients in this group, and 3.4% (5/146) of them received MT. A TBSS of 17 points or higher had a specificity of 97.8%, which included 72 patients, and 94.4% (68/72) of them received MT. Forty-six patients had a TBSS from 11 to 16 points (gray zone), and 26.1% (12/46) of them received MT. Comparing the MT group (12/46) and non-MT group (34/46), coagulopathy and extravasation on computed tomographic scan were more prevalent in the MT group. CONCLUSION The TBSS is highly accurate in predicting the need for MT, and a risk classification for needing MT was created based on TBSS.

Ex-vivo porcine organs with a circulation pump are effective for teaching hemostatic skills.

Surgical residents have insufficient opportunites to learn basic hemostatic skills from clinical experience alone. We designed an ex-vivo training system using porcine organs and a circulation pump to teach hemostatic skills. Residents were surveyed before and after the training and showed significant improvement in their self-confidence (1.83 ± 1.05 vs 3.33 ± 0.87, P < 0.01) on a 5 point Likert scale. This training may be effective to educate residents in basic hemostatic skills.

Self-inflicted injuries are an important cause of penetrating traumatic injuries in Japan

Japan has a low crime rate, but a high suicide rate. The aim of this study is to review the causes of penetrating traumatic injuries in a tertiary care emergency center in Japan.

Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis

A 74-year-old man with coronary artery disease was suffering from acute nonobstructive cholecystitis and was admitted to a nearby hospital. Dual antiplatelet (aspirin and ticlopidine) therapy was discontinued before preparation for surgical resection of the gall bladder. During his time in hospital he was aware of lumbar pain and weakness in both legs. He was transferred to our hospital for further evaluation and therapy. Diffuse intra-aortic thrombi were revealed by computed tomography with contrast media, and magnetic resonance imaging showed spinal cord infarction. However, computed tomography scans of the descending aorta obtained 4 months before admission exhibited no signs of atherosclerotic plaques or intra-aortic thrombi. Laboratory data suggest that antiphospholipid antibody syndrome might have caused these acute multiple intra-arterial thrombi. By restarting dual antiplatelet therapy and increasing the dose of heparin (from 10,000 IU/day to 15,000 IU/day) we successfully managed the patient’s clinical condition and symptoms. It is important to understand that stopping antiplatelet therapy may rapidly grow thrombi in patients with a hypercoagulative state.