[Acute penetrating neck trauma presenting with laryngotracheal injury].

Laryngotracheal injuries are serious complications in the case of penatrating neck trauma which may not commonly in Japan. In the last several decades, many authors have discussed method for accurate evaluation and immediate airway management for patient with laryngotracheal injury. But, standardization of the treatment is still controversial about mandatory exploration or selective exploration. We report 4 cases with fresh laryngotracheal injury due to penetrating neck trauma including 3 suicide attempt patients. In these cases, laryngotracheoplasty used by absorbable material was performed within 8 hours after trauma. Two cases of suicide attempt patients underwent tracheostomy at the lower level of the laryngotracheal injury. After these treatment, fiberoptic bronchoscopy was performed to evaluate the airway for 3 cases except 1 who was dead because of hemorrhagic shock on arrival. In 2 cases, the suture filament existed in the lumen of the larynx and trachea, there were no major granulation in the site of repairment and no infection. Three cases were extubated successfully and discharged without major airway problem. Two cases have psychiatric disease such as depression, so we must consider their psychiatric background in the future. In conclusion, penetrating laryngotracheal trauma, we should consider that serious airway injury may be hidden under the superficial small wounds. Also, rapid local wound exploration and laryngotracheoplasty is important for life-saving, and fiberoptic bronchoscopy is effective to prevent early respiratory complications and has value in the evaluation.

Transorbital penetrating injury by a chopstick--case report.

A one-year-old boy presented with orbitocranial penetrating injury by a chopstick. Neurological examination did not reveal abnormal findings. Skull radiography did not reveal any sign of fracture and there were no abnormal findings. Initially, computed tomography (CT) of the head did not reveal any intracranial lesions. However, bone window CT showed a well-defined low-density abnormality measuring 2.5 cm in length in the right orbit and parasellar region. Magnetic resonance imaging clearly revealed a low-intensity structure extending from the orbit to the prepontine area. Surgical exploration was emergently performed and the wooden fragment was removed. The postoperative course was uneventful. Transorbital penetrating injury by a wooden foreign body is relatively rare. The wound may be superficial and trivial. Major neurological deficit does not usually manifest immediately, so the penetrating injury may be overlooked. If the foreign body is retained in the orbit and cranium, severe infectious complications may occur later.

[Penetrating lung and diaphragmatic injuries with no abnormal finding of chest X-ray: a case report].

A case of penetrating lung and diaphragmatic injuries with no abnormal findings of chest X-ray is reported. A 76-year-old man was admitted to our hospital due to penetrating chest trauma. A simple X-ray film of the chest on admission revealed no abnormal finding. An emergency operation was performed. On exploring the back open wound, we found a laceration of 7 cm in diameter in the right diaphragm and lung laceration. Then we repaired primarily with absorbable material. The postoperative course was uneventful, and the patient was discharged 12 days later. Penetrating truncal traumas can result in diaphragmatic injury. Sometimes the clinical and roentgenographic findings are unreliable. If the diagnosis is missed, a diaphragmatic injury may occur delayed diaphragmatic hernias within hours to years. Accordingly, initial wound exploration are important for the diagnosis of diaphragmatic injury in avoiding serious complications.

Does the timing of hypertonic saline resuscitation affect its potential to prevent lung damage?

Hypertonic saline (HS) resuscitation has been reported to prevent lung damage by suppressing neutrophil activation in animal models. Data on the effectiveness of HS to prevent organ damage in the clinical setting are inconsistent. We investigated whether the timing of HS administration relative to neutrophil activation could affect its potential to block neutrophil responses. Different likely clinical circumstances were simulated in vitro by exposing human neutrophils to HS at different time points before and after activation with N-formyl-methionyl-leucyl-phenylalanine (fMLP). The in vivo effect of using HS as a secondary resuscitation fluid was determined with a mouse model of hemorrhage. BALB/c mice were hemorrhaged (40 +/- 5 mmHg) for 1 h and partially resuscitated with HS or Lactated Ringer's (LR) 20 min before completing resuscitation with LR or HS, respectively. Neutrophil activation parameters were determined 2 h after complete resuscitation and lung damage was assessed after 24 h. The length of exposure to physiologically relevant HS levels (20 mM) determined the suppressive effect on in vitro neutrophil superoxide formation. HS treatment caused a transient state of suppression during which neutrophil activation was suppressed; however, HS was unable to suppress cells that were stimulated with fMLP before HS was added. Accordingly, in vivo lung damage was greater in animals that received HS after they had been partially resuscitated with LR compared to mice that received HS before LR (P < 0.05). We conclude that timing of exposure to HS affects neutrophil responses in vitro and may reduce the potential of HS resuscitation to prevent lung injury in vivo.

[Surgical treatment for spontaneous hemopneumothorax complicated by delayed re-bleeding: a case report].

A 34-year-old man was admitted to the hospital due to spontaneous hemopneumothorax. A chest tube drainage was performed, and hemorrhagic plueral effusion of 1,600 ml was drained. Because of this, the patient was transferred to the emergency center of our hospital. Following a blood transfusion, we continued to treat conservatively for nine days, because no more bleeding was recognized. On day ten, the patient suddenly started bleeding again, thus, an emergency operation was performed. At the operation under a thoracoscope, a bleeding point was ligated with surgical clip, however, it was difficult to remove blood clots that were attached with the lung surface, it was impossible to continue the thoracoscopic surgery. If re-bleeding occurs after the acute phase, problems may arise from conservative treatment. So, early surgical treatment should be considered.

Continuous arterial infusion therapy for severe acute pancreatitis: correlation between CT arteriography and therapeutic effect.

PURPOSE: This study evaluates the relationship between the therapeutic effect of arterial infusion therapy for severe acute pancreatitis and drug distribution on CT-arteriography (CTA). MATERIALS AND METHODS: Eleven patients with severe acute pancreatitis were treated by arterial infusion with use of protease inhibitor and antibiotics. Ten patients had an inflammation of the entire pancreas, while one had pancreatitis localized to the body and tail of the pancreas. The arterial infusion drugs were infused into the celiac artery, splenic artery, inferior pancreaticoduodenal artery, and common hepatic artery. The drug distributions were evaluated by CTA in 10 patients. The duration of arterial infusion ranged from 3 to 39 days. The relationship between the distribution on the CTA and the change in clinical grading of pancreatitis as evaluated by an APACHE II score was studied. RESULTS: Of the nine patients with inflammation of the entire pancreas, six showed the distribution of contrast material to the entire area of pancreatic inflammation (a good distribution) on the CTA, and the remaining three did not show the distribution of contrast material to cover the entire area of pancreatic inflammation (a poor distribution). One patient with localized pancreatitis showed a good distribution. In seven patients with a good distribution, the APACHE II score was decreased from 11.7 points to 4.3 points during follow-up. In the remaining three patients with a poor distribution, the APACHE II score was decreased from 12.3 points to nine points, but was decreased to five points after the additional interventions. One patient without CTA showed a marked improvement in the APACHE II score. No clinically important complications were observed. CONCLUSION: The present study findings suggest that arterial infusion is effective in the treatment of severe acute pancreatitis. A good drug distribution to the area of inflammation is needed to ensure a proper therapeutic effect.

Increased plasma levels of adrenomedullin in patients with systemic inflammatory response syndrome.

We measured the plasma levels of adrenomedullin (AM), a novel vasodilating peptide, in 89 patients with various forms of systemic inflammatory response syndrome (SIRS) and 13 healthy volunteers serving as controls. Plasma levels of AM in SIRS (burns: 20.5 +/- 3. 2 fmol/ml [mean +/- SEM]; pancreatitis: 13.8 +/- 3.8 fmol/ml; trauma: 14.9 +/- 2.5 fmol/ml; traumatic shock: 41.1 +/- 7.8 fmol/ml; severe sepsis: 59.9 +/- 11.2 fmol/ml; septic shock: 193.5 +/- 30.1 fmol/ml) were significantly increased over those of controls (5.1 +/- 0.2 fmol/ml). The patients with traumatic shock or septic shock especially had higher levels of plasma AM than those with trauma or severe sepsis, respectively. These data showed that in patients with SIRS, plasma AM levels increased in proportion to the severity of illness. Subsequently, we measured the plasma levels of mediators such as tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, IL-8, plasminogen activator inhibitor (PAI)-1, and thrombomodulin (TM) in patients with traumatic shock and septic shock. A significant correlation was observed between plasma AM and TNF-alpha levels in patients with septic shock, suggesting an important role for AM as well as of TNF-alpha in the pathophysiology of inflammation. Plasma AM and IL-8 levels correlated positively with Acute Physiology and Chronic Health Evaluation (APACHE) II score, peak multiple organ failure (MOF) score during the first month and prognosis in patients with septic shock, as did plasma IL-6 levels in patients with traumatic shock. The plasma AM level might serve as a useful marker for evaluating the severity of disease and as an early predictor of subsequent organ failure and outcome in septic shock.

Posttraumatic intestinal stenosis presenting as a perforation: report of a case.

A 78-year-old woman was admitted to the hospital after falling into a ditch approximately 1 m deep and sustaining a blunt abdominal trauma with a left femur fracture. On the tenth day after admission, symptoms of a small bowel obstruction occurred. A nasogastric tube was inserted, and the symptoms thus improved. She sometimes complained of abdominal pain during the 12 months after the fall, but recovered with conservative management. The next year, she was readmitted to the hospital for a pin extraction of the left femur bone. During this admission, 15 months since her admission after her fall, she again complained of abdominal pain. Abdominal pain increased with a muscular defense, and abdominal X-rays revealed free air. She was referred to our hospital with a diagnosis of perforative peritonitis, and emergency surgery was performed. Upon laparotomy, circumferential stenoses of the small bowel were recognized in the proximal segments about 40cm, 80cm, and 100cm from the ileocecal region. In addition, a perforation and prominent dilatation of the bowel segment was observed just proximal to the stenosis about 100cm from the ileocecal region. She underwent a small intestinal resection at two sites. There were no findings of an intestinal specific ulcer, such as Crohn's disease, intestinal tuberculosis, or malignancy, based on the results of a histopathological examination.

[Thoraco-abdominal impalement injury with diaphragmatic injury: a case report].

A 60-year-old man was admitted to our hospital because of impalement injury due to traffic accident. Chest X-ray on admission revealed normal lung field. CT scans of the chest and abdomen revealed slight pneumothorax and intra-abdominal organ protruding from abdominal cavity. An emergency operation was performed. Diaphragmatic injury was not detected during the abdominal procedure. On exploring the back wound, we found a laceration of 8 cm in diameter in the diaphragm and repaired it. Impalement injuries which have aspects of both blunt and penetrating trauma are uncommon. Accordingly, wound exploration and debridement of fistulous tract are necessary. In the case of thoraco-abdominal injuries by impalement, one should bear in mind the existence of diaphragmatic injury even with normal diaphragmatic shadow on chest X-ray.

Primary adenocarcinoma of appendix, colonic type associated with perforating peritonitis in an elderly patient.

We report a case of colonic type adenocarcinoma of the appendix with perforating peritonitis in a 92-year-old man. The preoperative diagnosis was localized peritonitis due to acute appendicitis and emergency laparotomy was performed. A gray, hard tumor was palpated at the base of the appendix. Appendiceal cancer was suspected, and right hemicolectomy was performed. The histopathological diagnosis was moderately differentiated adenocarcinoma of the appendix. The tumor obstructed the orifice of the appendix, and this may have caused the perforation of the appendix. The patient had an uneventful postoperative course and there have been no signs of recurrence in the 2 years since the operation.

Increased plasma concentrations of adrenomedullin correlate with relaxation of vascular tone in patients with septic shock.

OBJECTIVE: To investigate plasma concentrations of adrenomedullin in patients with septic shock and the potential association of these concentrations with relaxation of vascular tone. DESIGN: Prospective, case series. SETTING: Department of Emergency and Critical Care Medicine, Nara Medical University. PATIENTS: Twelve patients who fulfilled the clinical criteria for severe sepsis or septic shock (as defined by the Members of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference Committee) and 13 healthy volunteers. INTERVENTIONS: Arterial blood samples were obtained via a 20-gauge cannula inserted into each patient's radial artery. MEASUREMENTS AND MAIN RESULTS: After extraction and purification, plasma adrenomedullin was measured by radioimmunoassay. Systemic vascular resistance index, pulmonary vascular resistance, cardiac index, and stroke volume index were determined with a thermodilution catheter. The mean plasma concentration of adrenomedullin was markedly higher in patients than in controls (226.1 +/- 66.4 [SEM] vs. 5.05 +/- 0.21 fmol/mL, p < .01). Moreover, these concentrations correlated significantly with cardiac index, stroke volume index, and heart rate values, and correlated significantly with decreases in diastolic blood pressure, systemic vascular resistance index, and pulmonary vascular resistance index values. CONCLUSIONS: Enhanced production of adrenomedullin in patients with septic shock may contribute to reduced vascular tone, hypotension, or both. More data are needed to clarify the role of adrenomedullin in the regulation of vascular tone in this patient population.

[Cerebral infarction due to bacterial emboli associated with methamphetamine abuse].

The number of stimulant-drug addicts has recently been on the rise again, and they are being increasingly encountered in the emergency room. There are also frequent reports of cerebrovascular disorders complicating drug toxicity. These cerebrovascular disorders have included subarachnoid hemorrhage, intracranial hematoma, and a few cases of cerebral infarction. Here, we report the case of a 37-year-old male with drug toxicity, consciousness disorder, and hyperthermia. He was in a coma with a temperature of 43.1 degrees C and blood pressure of 58/35 mmHg when brought to our hospital. His condition worse rapidly deteriorated, and he died the same day. Cerebral infarction caused by gram-positive bacillus embolism, not necrotizing angiitis, was found at autopsy. Because drug addicts, especially stimulant-drug addicts, tend to inject themselves drug under unsanitary conditions, the possibility of this type of complication is always present. This is the first such case ever reported, and is therefore regarded as a rare complication of stimulant-drug intoxication.

[A case report of spontaneous hemopneumothorax].

A 55-year-old man was admitted to the private hospital with chief complaints of left chest pain and increasing dyspnea. Chest X ray on admission revealed a collapsed lung and an air fluid line in the left hemothorax. A chest tube drainage was carried out, but hemorrhagic pleural fluid of 1,000 ml was drainaged. So was the patient transferred to our hospital for surgical treatment. Following blood transfusion because of hemorrhagic pleural fluid of 1,500 ml, urgent surgery was carried out. At the operation under thoracoscope, the bleeding from the apex of the thoracic cavity was noted. The bleeding was controlled with endoscopic surgical clip. As it was, however, very difficult to remove massive blood clots under endoscopic surgery, a small thoracotomy was carried out in addition to the thoracoscopic surgery, then the bulla in the apex of left lung was resected and also removed a large amount of blood clots.

Preoperative administration of antibiotics in patients with suspected acute appendicitis.

The effectiveness of administering antibiotics preoperatively to patients with suspected appendicitis was evaluated over a 2-year period in 105 consecutive patients who presented with right lower quadrant (RLQ) tenderness and a white blood cell (WBC) count of over 10,000/mm3 or a temperature of over 37 degrees C. All the patients were preoperatively administered cefazolin (CEZ), cefotiam (CTM), or fosfomycin (FOM) except those with apparent peritonitis, which resulted in the recovery of 41 patients (39%). Of the remaining 64 patients, 14 (13%) had catarrhal appendicitis, 34 (32%), phlegmonous appendicitis, and 16 (15%), gangrenous appendicitis. Preoperatively, there were no significant differences among these groups in the WBC count or temperature. Following the administration of antibiotics, both these parameters decreased significantly in the patients with catarrhal appendicitis, although a slight RLQ tenderness persisted; in those with phlegmonous appendicitis, the WBC count decreased significantly, but the temperature remained elevated, with slight rebound tenderness in the RLQ; and in those with gangrenous appendicitis, there were no significant differences between the pre- and postoperative data in WBC count or temperature, and the abdominal symptoms did not change. These results show the value of administering antibiotics within 24h of the onset of symptoms indicative of acute appendicitis to allow time to evaluate the patients' condition, decide the operative indications, and prevent unnecessary laparotomy.

[A successful management of acute ruptures of the right atrium and left ventricle due to blunt trauma].

It is difficult to save a patient with acute cardiac free wall rupture due to blunt trauma; only 9 patients abroad and 2 patients in Japan are reported to have survived rupture of the left ventricle. A 30-year-old female was injured in a motor-vehicle accident. Distension of the neck vein, chest X-P and echocardiograms suggested cardiac tamponade due to cardiac rupture. After relieving the cardiac tamponade by left thoractomy, ruptures at the apex of the left ventricle and two sites in the right atrium could be repaired by median sternotomy, and the patient survived the injury. Cardiac rupture should be suspected in all cases of blunt trauma, and the early diagnosis of cardiac tamponade is a key to patient survival. Echocardiography is especially convenient and useful for the diagnosis of this condition. Repair should be performed by median sternotomy and the potential necessity for cardiopulmonary bypass should not be ignored.

Neurofibroma of the stomach: report of a case.

We report herein the case of a 71-year-old-Japanese woman who was admitted to hospital for surgical treatment of a lower abdominal tumor. At laparotomy the tumor was found to be pedunculated and growing extramurally from the greater curvature of the stomach. Thus, a wedge resection of the stomach, including the mass, was performed. The tumor measured about 9 x 8 x 7 cm and histological examination of the resected specimen showed that the main elements consisted of wavy, long-spindled cells, which crossed irregularly, indicating that it was palisading negative. Immunohistochemically, the specimen was positive for both S-100 protein and Alcian blue. From these findings, the tumor was histologically diagnosed as a neurofibroma. The patient had an uneventful postoperative course and no signs of recurrence have been recognized in the 3 years since her operation.

[2 cases of the tension pneumopericardium following blunt chest trauma resulting in the cardiac tamponade].

A 63-year-old man (case 1) was brought to our emergency unit following a high speed collision. He developed fatal cardiopulmonary arrest shortly after arrival despite resuscitation efforts. Tension pneumopericardium was revealed by chest X-ray and CT examination. An 18-year-old man (case 2) was admitted after a motorcycle accident. Pneumopericardium was noted on admission chest X-ray and CT examination. He developed cardiac tamponade after the examination. He was intubated and mechanically ventilated after the subxiphoid pericardial drainage. Pneumopericardium following blunt chest trauma is realized with tracheobronchial, pulmonary or esophageal injury. The clinical significance of pneumopericardium is the development of tension pneumopericardium resulting into cardiac tamponade. In a patient with traumatic pneumopericardium who requires mechanical ventilatory support, continuous pericardial drainage should be considered. In addition, tension pneumopericardium may occur in patients with breathing spontaneously as in our cases. In these cases, careful observation and immediate subxiphoid pericardial drainage are required.

Evaluation of initial hepatic allograft function with changes of free plasma amino acids in canine orthotopic liver transplantation.

We investigated the correlation between amino acid level and hepatic graft function. Plasma amino acid levels were measured at three time periods during canine orthotopic liver transplantation. During the anhepatic phase, plasma amino acid levels rose except for tryptophan. Cystine and alanine (Ala) increased significantly to 210 +/- 28% (n = 20, mean +/- SEM) and 203 +/- 11% from preoperative values (100%), respectively. In animals successfully surviving without hepatic insufficiency after transplantation of fresh livers (n = 7), plasma amino acid levels were restored to preoperative values within 3 hr following reperfusion. On the other hand, in animals that died from hepatic insufficiency within 5 days after grafting of warm ischemically damaged livers (n = 8), plasma amino acids, especially Ala, phenylalanine, total free plasma amino acids, and aromatic amino acids progressively increased to 216 +/- 25, 274 +/- 36, 152 +/- 15, and 152 +/- 15% at 3 hr after reperfusion. These were significantly higher compared to those of the group of animals transplanted with fresh livers (P less than 0.01-0.05). Furthermore, higher values were found in those dogs transplanted with warm ischemically damaged livers surviving for shorter periods. Also in dogs that died from hepatic insufficiency within 8 hr after grafting of livers preserved for 24 hr (n = 5), amino acid levels were at high values at 3 hr. These results suggest that in animals having good graft function, plasma amino acid levels are restored to preoperative values by 3 hr after reperfusion. In other cases, primary nonfunction should be strongly suspected after liver transplantation.

The immunosuppressive effect of hepatocytes in rats--assessment by heart allograft survival and delayed-type-hypersensitivity reactions.

The immunosuppressive effect of hepatocytes was examined experimentally by heart allograft and delayed-type-hypersensitivity (DTH) reactions. The hepatocyte inoculation (1 X 10(7) of BDE (of the major histocompatibility complex haplotype RT1u), LEW (RT1l), and DA (RT1a) into the spleens of LEW rats significantly prolonged the survival of BDE heart allografts to 14.3 +/- 2.7 (mean +/- SD), 9.2 +/- 0.8, and 10.8 +/- 2.3 days respectively, compared with 6.7 +/- 0.8 days in controls (p less than 0.01). Moreover, the BDE hepatocytes had a significantly prolonged survival compared to the LEW (p less than 0.01) and DA (0.02 less than p less than 0.05) groups. BDE hepatocyte (donor specific) inoculation 4 and 7 days before priming with the spleen cells reduced DTH responses in the LEW rats to 44.6 +/- 4.8 per cent, and 74.2 +/- 8.0 per cent, respectively. DA hepatocyte inoculation (third party) 4 and 7 days prior to priming reduced DTH responses to 72.5 +/- 11.5 per cent, and 76.5 +/- 11.9 per cent, respectively. All DTH responses were significantly suppressed after hepatocyte inoculation compared to 100 per cent in the controls (p less than 0.01). Moreover, the inoculation of BDE hepatocytes (donor specific) 4 days prior to the priming significantly reduced DTH responses compared to the group primed 7 days before (p less than 0.01). From these results we concluded that hepatocytes produced not only non-specific but also donor specific immunosuppressive effects through T cell immune reaction. Moreover, donor specific immunosuppressive effects were induced at least 4 to 7 days after hepatocyte inoculation.