Survival benefits of interventional radiology and surgical teams collaboration during primary trauma surveys: a single-centre retrospective cohort study.

BACKGROUND: A team approach is essential for effective trauma management. Close collaboration between interventional radiologists and surgeons during the initial management of trauma patients is important for prompt and accurate trauma care. This study aimed to determine whether trauma patients benefit from close collaboration between interventional radiology (IR) and surgical teams during the primary trauma survey. METHODS: A retrospective observational study was conducted between 2014 and 2021 at a single institution. Patients were assigned to an embolization group (EG), a surgery group (SG), or a combination group (CG) according to their treatment. The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course of treatment. RESULTS: The analysis included 197 patients, consisting of 135 men and 62 women, with a median age of 56 [IQR, 38-72] years and an injury severity score of 20 [10-29]. The EG, SG, and CG included 114, 48, and 35 patients, respectively. Differences in organ injury patterns were observed between the three groups. In-hospital survival rates in all three groups were higher than the Ps. In particular, the survival rate in the CG was 15.5% higher than the Ps (95% CI: 7.5-23.6%; p < 0.001). In the CG, the median time for starting the initial procedure was 53 [37-79] min and the procedure times for IR and surgery were 48 [29-72] min and 63 [35-94] min, respectively. Those times were significantly shorter among three groups. CONCLUSION: Close collaboration between IR and surgical teams, including the primary survey, improves the survival of severe trauma patients who require both IR procedures and surgeries by improving appropriate treatment selection and reducing the time process.

Unveiling the Rare Presentation of Acetylsalicylate Overdose: Grand Round.

BACKGROUND: This case report highlights a rare occurrence of aspirin overdose presenting only as severe coagulopathy. CASE PRESENTATION: An 85-year-old woman was admitted to the hospital with multiple lumbar vertebral compression fractures causing severe back pain. The patient had self-medicated with excessive consumption of Bufferin A containing 330 mg of aspirin. On arrival, she showed no typical symptoms of salicylate toxicity, such as nausea, vomiting, hyperventilation, tinnitus, or hearing loss. However, blood work revealed a significant decrease in vitamin K-dependent coagulation factors leading to coagulopathy. The administration of 20-mg menatetrenone (vitamin K) resulted in rapid improvement in coagulation abnormalities. The patient's blood salicylate level was later determined to be 42.7 mg/dL. DISCUSSION: Acute salicylate poisoning is known to cause coagulopathy because of the inhibition of vitamin K-dependent coagulation factors. However, this case is unique because it demonstrates coagulopathy as the sole manifestation of aspirin toxicity without any other symptoms. CONCLUSIONS: This case highlights the importance of considering the possibility of aspirin toxicity in patients with coagulopathy, especially those who are regularly consuming aspirin.

Severe aconite poisoning successfully treated with veno-arterial extracorporeal membrane oxygenation: A case report.

BACKGROUND: Most species of aconite contain highly toxic aconitines, the oral ingestion of which can be fatal, primarily because they cause ventricular arrhythmias. We describe a case of severe aconite poisoning that was successfully treated through veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and in which detailed toxicological analyses of the aconite roots and biological samples were performed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). CASE SUMMARY: A 23-year-old male presented to the emergency room with circulatory collapse and ventricular arrhythmia after ingesting approximately half of a root labeled, "Aconitum japonicum Thunb". Two hours after arrival, VA-ECMO was initiated as circulatory collapse became refractory to antiarrhythmics and vasopressors. Nine hours after arrival, an electrocardiogram revealed a return to sinus rhythm. The patient was weaned off VA-ECMO and the ventilator on hospital days 3 and 5, respectively. On hospital day 15, he was transferred to a psychiatric hospital. The other half of the root and his biological samples were toxicologically analyzed using LC-MS/MS, revealing 244.3 mg/kg of aconitine and 24.7 mg/kg of mesaconitine in the root. Serum on admission contained 1.50 ng/mL of aconitine. Beyond hospital day 2, neither were detected. Urine on admission showed 149.09 ng/mL of aconitine and 3.59 ng/mL of mesaconitine, but these rapidly decreased after hospital day 3. CONCLUSION: The key to saving the life of a patient with severe aconite poisoning is to introduce VA-ECMO as soon as possible.

Poisoning by abnormally high blood phenobarbital concentration treated with extracorporeal therapy.

Phenobarbital poisoning, which may cause circulatory collapse as well as respiratory arrest in severe cases, has one of the highest mortality rates among acute drug poisonings. A 58-year-old man arrived at the emergency room in a deep coma (Glasgow Coma Scale E1V1M1) after taking an unknown dose of phenobarbital which had been prescribed for his cat's seizures. Venous blood gas analysis revealed hypercapnia (PvCO2: 113.0 mmHg) and a blood phenobarbital concentration of 197.3 µg/mL. Shortly after his arrival, respiratory arrest and circulatory collapse occurred. Mechanical ventilation after intubation, intravenous noradrenaline infusion, and multiple-dose activated charcoal through a nasogastric tube was started. Six hours after arrival, blood phenobarbital concentration was abnormally elevated to 356.8 µg/mL with circulatory collapse requiring an increased dose of intravenous noradrenaline infusion (up to 0.13 µg/kg/min). Continuous renal replacement therapy including high flow continuous hemodialysis was performed until hospital day 5, during which blood phenobarbital concentration decreased to 96.2 µg/mL on hospital day 4, resulting in a sufficient resumption of spontaneous breathing and full improvement of circulatory collapse. A search of the literature revealed that the peak phenobarbital concentration in the present case exceeded those of fatal cases, as well as those of survivors of acute phenobarbital poisoning. However, the patient was successfully treated with continuous renal replacement therapy. Among modalities of extracorporeal treatment, continuous renal replacement therapy could be considered if a patient's circulation is unstable.

Effect of Carbazochrome Sodium Sulfonate in Addition to Tranexamic Acid in Bleeding Trauma Patients.

BACKGROUND: It is important to evaluate the effects of drugs considered to control hemorrhage. Tranexamic acid (TXA) has been shown to reduce the risk of death in bleeding trauma patients. Carbazochrome sodium sulfonate (CSS) is often used in combination with TXA; however, it is unknown whether CSS additionally improves the control of bleeding in trauma patients. METHODS: The aim of this study was to examine whether CSS reduces blood transfusion and death in addition to TXA by improving the control of bleeding. We retrospectively analyzed medical records of trauma patients from 2011 to 2019. We included patients aged ≥16 years, with significant hemorrhage, and who received TXA within eight hours from injury as per CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) study. The primary outcome was the total amount of red blood cells (RBC), fresh frozen plasma (FFP), and platelet concentrate (PC) received within the first 24 hours from injury. Secondary outcomes were death in hospital within four weeks after injury, vascular occlusive events, and treatment. RESULTS: During this retrospective evaluation period, 5764 admissions with trauma were registered. A total of 326 cases met the selection criteria: 259 cases who received CSS in addition to TXA (CSS group; n=259) and 67 cases who received only TXA (no-CSS group; n=67). The mortality rate was 6% in the no-CSS group and 15.1% in the CSS group. There was no significant difference in mortality and vascular occlusive events between the two groups. We performed multiple regression analyses, with the amount of blood transfusion for each type as explanatory variables. The administration of CSS was an independent factor for the reduction of RBC transfusion (standard partial regression coefficient -0.1, 95% CI [-3.1 to -0.1], p=0.04), but not for transfusion of FFP or PC. We also performed multiple logistic regression analysis, with death as an explanatory variable. CSS was not an independent factor for any cause of death. CONCLUSION: CSS decreased RBC transfusion in trauma patients, without increasing the risk of vascular occlusion. However, CSS did not decrease mortality. This study can contribute to managing bleeding with trauma, but further research aimed at clarifying the effect of CSS is needed.

The effect of participation of interventional radiology team in a primary trauma survey on patient outcome.

PURPOSE: The purpose of this study was to examine the survival benefits of a workflow in which an interventional radiology (IR) team participates in a primary trauma survey on patients with hemodynamically unstable trauma. MATERIALS AND METHODS: A retrospective observational study was conducted between 2012 and 2019 at a single institution. Patients who underwent an IR procedure as the initial hemostasis were assigned to the hemodynamically stable group (HSG) or hemodynamically unstable group (HUG). The primary and secondary outcomes were survival at hospital discharge compared with the probability of survival (Ps) and the time course. RESULTS: A total of 160 patients (100 men, 60 women; median age, 57.5 years [interquartile range (IQR): 31.5-72 years]) with an injury severity score of 24 (IQR: 13.75-34) were included. A total of 125 patients were included in the HSG group and 35 patients in the HUG group. The observational survival rate was significantly greater than the Ps rate by 4.9% (95% confidence interval [CI]: 1.6-8.4%; P = 0.005) in HSG and by 24.6% in HUG (95% CI: 16.9-32.3%; P < 0.001). The observational survival rate was significantly greater than Ps in HUG than in HSG (P < 0.001). The median time to initiate IR procedures and the median procedure time in HUG were 54 min [IQR: 45-66 min] and 48 min [IQR: 30-85 min], respectively; both were significantly shorter than those in the HSG. CONCLUSION: A trauma workflow utilizing an IR team in a primary survey is associated with improved survival of patients with hemodynamically unstable trauma when compared with Ps with a shorter time course.

Preoperative physical functional status affects the long-term outcomes of elderly patients with open abdomen.

AIM: The mortality rates among elderly patients with open abdomen (OA) are high, and pre-existing comorbidities could affect the outcomes. However, long-term prognosis remains uncertain. We examined long-term outcomes in elderly patients with OA, focusing on physical functional status. METHODS: We undertook a retrospective cohort study between 2007 and 2017 at a single institution. Patients with OA who were aged ≥65 years were categorized into two groups: "good preoperative functional status" group (GFG) and "poor preoperative functional status" group (PFG). The GFG was defined as Eastern Cooperative Oncology Group/World Health Organization performance status (PS) 0-1, whereas PFG was defined as PS 2-4. The primary outcomes were survival and PS 2 years following the initial surgery. RESULTS: Of the 53 participants, 38 and 15 were assigned to the GFG and PFG, respectively. The PFG (median age, 81 years) was older than the GFG (median age, 75.5 years; P = 0.040). The 2-year survival rate was 39.5% in GFG and 6.7% in PFG, and Kaplan-Meier analysis showed significant difference (P = 0.022). Among all patients, the PS at 2 years was worse than that at discharge (P = 0.007). Preoperative PS was correlated with 2-year survival (P = 0.003), whereas age and pre-existing comorbidities were not. CONCLUSION: The long-term outcomes of elderly patients with OA are affected by the preoperative physical functional status. Functional status deteriorates in a time-dependent manner. Therefore, surgery requiring OA must be carefully considered for elderly patients with PS 2 or higher.

Successful use of the two-tube approach for the treatment of phenobarbital poisoning without hemodialysis.

Half-life of the antipsychotic vegetamin is very long, partially due to the presence of phenobarbital, and mortality due to phenobarbital poisoning is high. Here, we present the case of a 22-year-old female admitted to the emergency department with disturbed consciousness due to vegetamin overdose. Her blood phenobarbital level was elevated to 123 µg/ml. Phenobarbital undergoes enterohepatic circulation, and its retention in the intestine causes its blood levels to remain sustained. The utility of hemodialysis for drug poisoning has been previously reported; however, its efficiency is not yet established and its efficacy is low for drugs with long half-lives such as phenobarbital. Therefore, we performed a two-tube approach to adsorb phenobarbital in the intestines with activated charcoal delivered via a gastric tube and to remove the phenobarbital-adsorbed activated charcoal using whole bowel irrigation via an ileus tube 2 h later. The patient successfully eliminated the charcoal via stool, the blood phenobarbital level decreased drastically without hemodialysis, and the clinical course improved. We propose that this two-tube approach is suitable for treatment of poisoning with drugs that undergo enterohepatic circulation and have long half-lives.

Thyroid hormone alterations in trauma patients requiring massive transfusion: An observational study.

BACKGROUND: Although non-thyroidal illness syndrome (NTIS) is considered a negative prognostic factor, the alterations in free triiodothyronine (fT3) levels in trauma patients requiring massive transfusion have not been reported. METHODS: A prospective observational study comparing 2 groups of trauma patients was conducted. Group M comprised trauma patients requiring massive transfusions (>10 units of packed red blood cells) within 24 hours of emergency admission. Group C comprised patients with an injury severity score >9 but not requiring massive transfusions. Levels of fT3, free thyroxine (fT4), and thyroid-stimulating hormone (TSH) were evaluated on admission and on days 1, 2, and 7 after admission. The clinical backgrounds and variables measured including total transfusion amounts were compared and the inter-group prognosis was evaluated. Results are presented as mean±standard deviation. RESULTS: Nineteen patients were enrolled in each group. In both groups, 32 were men, and the mean age was 50±24 years. In group C one patient died from respiratory failure. The initial fT3 levels in group M (1.95±0.37 pg/mL) were significantly lower than those in group C (2.49±0.72 pg/mL; P<0.01) and remained low until 1 week after admission. Initial inter-group fT4 and TSH levels were not significantly different. TSH levels at 1 week (1.99±1.64 µIU/mL) were higher than at admission (1.48±0.5 µIU/mL) in group C (P<0.05). CONCLUSION: Typical NTIS was observed in trauma patients requiring massive transfusions. When initial resuscitation achieved circulatory stabilization, prognosis was not strongly associated with NTIS.

Management of a gluteal region impalement injury caused by three reinforced aluminum bars: a case report.

INTRODUCTION: Impalement injuries with multiple objects are rare and their management is complex. Rapid confirmation of vascular injuries requiring urgent endovascular or surgical management and accurate location of multiple objects are essential for efficient preoperative management. We report the case of a patient with septic shock secondary to a perforated rectum caused by an impalement injury with three reinforced aluminum bars. CASE PRESENTATION: A 58-year-old Asian man fell from the roof of a house and received gluteal impalement injuries from three reinforced aluminum bars. A physical examination showed paralysis of his left leg and no active bleeding from the insertion sites of the impaled objects. Multidetector computed tomography angiography confirmed the location of the aluminum bars, which had spared his small bowel, ureter and major vessels. No significant extravasation was observed. Two bars were successfully removed under general anesthesia in the lithotomy position. The third bar, which pierced his rectum, passed through the left side of his vertebrae and extended up to the superior side of his left kidney, was removed following a celiotomy. After removal of this bar, bleeding from the anterior side of the sacral bone was controlled by gauze packing. After surgery, our patient was admitted to our intensive care unit under endotracheal intubation and mechanical ventilation. Dopamine therapy was initiated, followed by direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) for septic shock secondary to a perforated rectum. This treatment was continued for two hours, resulting in stabilization of our patient's hemodynamic condition. Daily peritoneal lavage was performed for several days, along with a colostomy. Although there were motor and sensory disturbances below the L3 level, there were no complications. On day 191 of admission, our patient was discharged with motor and sensory disturbances below the L3 level. He now uses a wheelchair and depends on assistance from others for daily activities. CONCLUSION: Preoperative multidetector computed tomography angiography confirmed the anatomic location of the aluminum bars and the absence of extravasation; these findings aided in treatment planning. Our patient was successfully managed by colostomy and aggressive surgical and critical care including direct hemoperfusion with polymyxin B-immobilized fiber, and developed no intra-abdominal infection or meningitis.

Surveillance of the clinical use of mamushi (Gloydius blomhoffii) antivenom in tertiary care centers in Japan.

We report the results of the first large-scale questionnaire surveillance on the clinical use of pit viper antivenom in tertiary care centers in Japan. The questionnaire surveillance was conducted over a period of 3 years (April 2006 to March 2009). Completed questionnaires were received from the tertiary care centers of 108 (49.3%) medical institutions. In that period, 574 cases of pit viper bites, including 2 severe cases, were reported. Antivenom was administered in 44% of the cases of pit viper bites, and of these cases, 2.4% had adverse reactions but no severe symptoms. Approximately half of the clinicians indicated that antivenom was effective. Antivenom was recognized to be safe; however, the remarkable finding was that although the severity of treated cases was unclear, some clinicians reported using cepharanthine as the first choice of treatment for pit viper bites.

Gluteal Soft Tissue Necrosis After Transcatheter Angiographic Embolization for Pelvic Fracture: a Report of Two Cases.

In this paper, two cases of the gluteal soft tissue necrosis after pelvic fractures will be discussed. In the case of a 29-year-old man, a localized area of skin necrosis on the buttock appeared after transcatheter arterial embolization (TAE) of the right internal iliac artery (IIA). In the second case, a 52-year-old man, who was treated using TAE of the bilateral IIA's, developed an extensive area of necrosis in the gluteus maximus muscle with subsequent severe infection. In both cases, complete excision of the necrotic tissue and reconstructive flap surgery were imperative. Gluteal soft tissue necrosis is clinically important as one of the serious complications of TAE.