[Primary central nervous system vasculitis: a differential diagnosis of longitudinally extensive spinal cord lesion].

A 63-year-old man was admitted to our hospital with a 2-month history of anxiety. He presented with cognitive impairment and muscle weakness. On MRI, T2-weighted images showed longitudinally extensive spinal cord lesion (LESCL) from C2 to T6 and gadolinium-enhanced T1-weighted images showed fan-shaped multiple linear enhancements converging to the lateral ventricles. He was diagnosed as primary central nervous system vasculitis (PCNSV) by brain biopsy. After using high dose corticosteroids, cognitive impairment and muscle weakness were dramatically improved. In patients with cognitive impairment, PCNSV should be included in the differential diagnosis of LESCL.

Investigation of anti-inflammatory effects of oxygen nanobubbles in a rat hydrochloric acid lung injury model.

Aim: To investigate the anti-inflammatory effect of oxygen nanobubbles (ONBs) in an acute lung injury rat model. Materials & methods: In a rat hydrochloric acid lung injury model, ONB fluid was administered intravenously in the ONB group (n = 6) and normal saline was administered in the control group (n = 6). 4 h later, arterial partial pressure of oxygen (PaO2), mean arterial pressure and plasma inflammatory cytokines were measured. Results: There were no significant differences in the PaO2, mean arterial pressure or TNF-α and IL-6 levels between the two groups. Conclusions: No anti-inflammatory effect could be confirmed at the present ONB dose in the rat model of acute lung injury.

Effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) measurement.

To retrospectively investigate the effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) in 20 patients who underwent elective gynecologic surgery under general anesthesia. The study subjects were patients who underwent elective gynecologic surgery under general anesthesia between April 2016 and January 2017, and were administered a 5-ml intravenous injection of 0.4% indigo carmine for clinical purposes during surgery with ORi monitoring. Changes in ORi within 20 min after indigo carmine injection were observed. A relevant decrease in ORi was defined as ≥ 10% reduction in ORi from pre-injection level. ORi rapidly decreased after indigo carmine intravenous injection in all patients. In 10 of 19 patients, ORi decreased to 0 after indigo carmine injection. The median lowest value of ORi was 0 (range 0-0.16) and the median time to reach the lowest value of ORi was 2 min (range 1-4 min) after injection. ORi values returned to pre-injection levels within 20 min in 13 of 19 patients, and the median time to return to pre-injection levels was 10 min (range 6-16 min) after injection. During ORi monitoring it is necessary to consider the rapid reduction in ORi after intravenous injection of indigo carmine.

Anesthetic Management of a Patient With Antimuscle-Specific Kinase Antibody-Positive Myasthenia Gravis Undergoing an Open Cholecystectomy: A Case Report.

Myasthenia gravis (MG) is an autoimmune disease characterized by the production of antibodies against the acetylcholine receptor, muscle-specific kinase (MuSK), or other proteins at the neuromuscular junction. MG with antibodies against MuSK (MuSK-MG) has been described recently. Here, we report the first case of anesthetic management of a patient with MuSK-MG undergoing an open cholecystectomy. In our case, propofol and remifentanil-based anesthesia were used for successful management without using muscle relaxants. Patients with MuSK-MG have predominantly ocular, bulbar, and respiratory symptoms that may increase the risk of aspiration. Anesthesiologists need to pay attention to perioperative respiratory failure and respiratory crisis.

Effects of indigo carmine intravenous injection on noninvasive and continuous total hemoglobin measurement with using the Revision L sensor.

The effects of intravenous injection of indigo carmine on noninvasive and continuous total hemoglobin (SpHb) measurement were retrospectively evaluated with the Revision L sensor. The subjects were 18 patients who underwent elective gynecologic surgery under general anesthesia. During surgery, 5 mL of 0.4 % indigo carmine was injected intravenously, and changes in SpHb concentrations between before and after the injection were evaluated. The mean age was 52.4 ± 12.8 years. Before injection, the median SpHb level was 10.1 (range, 6.8-13.4) g/dL. The results demonstrated no change in SpHb concentration between before and after indigo carmine injection as detected by the Revision L sensor. SpHb measurements as determined with the Revision L sensor were not affected, even after the intravenous injection of indigo carmine.

Life-threatening urethral hemorrhage after placement of a Foley catheter in a patient with uroseptic disseminated intravascular coagulation due to chronic urinary retention induced by untreated benign prostatic hyperplasia.

Case: A 77-year-old man with severe septic disseminated intravascular coagulation following urinary infection was transported to our hospital. He had developed urinary retention induced by untreated prostatic hyperplasia. Immediate drainage with a Foley catheter was successfully carried out, but the hematuria progressed to life-threatening hemorrhage. Outcome: Complete hemostasis was impossible by surgical treatment because the tissue around the prostatic urethra was very fragile and hemorrhagic. Organized treatments (continuous hemodiafiltration combined with polymyxin-B immobilized fiber column hemoperfusion and systemic treatment with antibiotics and coagulation factors) were commenced soon after the operation. The patient eventually recovered from the septic disseminated intravascular coagulation. Conclusion: This case report illustrates the risk of placement of Foley catheters in patients with severe septic disseminated intravascular coagulation.

Effects of indigo carmine intravenous injection on noninvasive and continuous total hemoglobin measurement.

The effects of an intravenous injection of indigo carmine on noninvasive and continuous total hemoglobin (SpHb) measurement were retrospectively evaluated. The subjects were 21 patients who underwent elective gynecologic surgery under general anesthesia. During surgery, 5 mL of 0.4 % indigo carmine was intravenously injected, and subsequent changes in SpHb concentrations were evaluated. The results demonstrate that the pre-injection SpHb level was 10 g/dL, and the minimum post-injection SpHb level was 8.3 g/dL. The amount of decrease was 1.8 g/dL. The time to reach the minimum value was 4 min, and the time to return to the pre-injection value was 15 min. The decrease in SpHb was greater in the group with a perfusion index (PI) < 1.4 than in the group with a PI > 1.4. The assessment of SpHb after an intravenous injection of indigo carmine necessitates caution.

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

INTRODUCTION: Computed 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. METHODS: WE 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. RESULTS: Before 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. CONCLUSION: Our 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.

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.

Development of takotsubo cardiomyopathy with severe pulmonary edema before a cesarean section.

Takotsubo cardiomyopathy is an acute syndrome involving apical ballooning and consequent dysfunction of the left ventricle. Most cases of left ventricular dysfunction resolve within 1 month. We present the case of a 40-year-old woman who developed severe heart failure caused by takotsubo cardiomyopathy with severe left ventricular dysfunction during the perinatal period. Because of the presence of multiple myomas, she was scheduled to undergo a cesarean section under general anesthesia. However, after induction of general anesthesia, she had to be awakened because of the presence of a difficult airway. Because she exhibited insufficient oxygenation, she was transferred to the emergency center. Upon hospital admission, she expectorated large amounts of pink sputum, indicating severe pulmonary edema. Cesarean section was performed immediately. Echocardiography revealed severe left ventricular dysfunction. Full recovery of cardiac function required almost 1 month, after which she was discharged from the hospital without further complications. This is the first reported case of takotsubo cardiomyopathy induced by a failed intubation during a scheduled cesarean section. Takotsubo cardiomyopathy usually shows a good prognosis, but if this myopathy develops during the perinatal period, it can worsen because of excessive preload following the termination of fetoplacental circulation.

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

BACKGROUND: Tracheotomy 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. METHODS: We 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. RESULTS: We 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. CONCLUSIONS: This 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.

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

AIM: To evaluate the usefulness of the initial diagnostic tests carried out in blunt trauma patients in our emergency department. METHODS: Blunt trauma patients admitted between October 2009 and October 2011 were retrospectively reviewed. A scoring system was developed (0 to 28 points) to differentiate between potential major trauma patients and physiologically stable patients. Patients were classified into three groups: Group I (minor trauma), revised trauma score normal and our score 0-14; Group II (potential major trauma), revised trauma score normal and our score 15-28; Group III (major trauma), revised trauma score low. The proportions of patients with positive initial diagnostic test results (blood tests, X-rays, and computed tomography) were determined in each group. RESULTS: The study included 1,291 patients (Group I, 1,019; Group II, 85; Group III, 187). Blood tests and X-rays were carried out frequently in all groups, but positive results were infrequent in Group I. Comparisons using Pearson's χ2-test showed significant differences in the proportions of patients with positive blood test, X-ray, and computed tomography results among the three groups. The proportions of patients with positive blood test and chest X-ray results were significantly lower in Group II than in Group III, but there were no significant differences in the proportions of patients with other positive results between these two groups. CONCLUSIONS: In physiologically stable blunt trauma patients, diagnostic tests should be selected only after careful patient evaluation. To achieve this, standardized criteria for the identification of minor trauma patients should be established.

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 Tukey's 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.

[Case of iodism complicated with severe airway stenosis due to pharyngolaryngeal edema].

A 22-year-old man was admitted to our hospital with dilute iodine tincture poisoning. He had ingested 150 mL in a suicide attempt. On arrival, he was in need of urgent airway management as he was repeatedly vomiting. Although we had difficulty with endotracheal intubation because of remarkable pharyngolaryngeal mucosal edema induced by dilute iodine tincture, we managed to secure the airway. On the 2nd day, laryngoscope showed severe mucosal erosion from the upper to middle pharynx and epiglottis. On the 4th day, we performed a tracheoctomy in anticipation of prolonged airway management. On the 16th day, laryngoscopy showed improvement in each of the 2nd day findings. On the 30th day, the patient was transferred to a psychiatric hospital. Generally, iodine poisoning induces multiple organ disorders and there have been several reports describing iatrogenic iodine poisoning. However, cases of severe airway stenosis due to ingestion of iodine are very rare. Presently, members of the public can easily purchase dilute iodine tincture in Japan, therefore emergency medical personnel should be aware of iodine poisoning as a method of suicide attempt.

Case of scrub typhus complicated by severe disseminated intravascular coagulation and death.

Scrub typhus is an infectious disease that is caused by Orientia tsutsugamushi. The authors describe an autopsied case of scrub typhus complicated with severe disseminated intravascular coagulation (DIC). An 82-year-old man complained of fever 4 days after climbing a mountain. The patient was admitted to an urban hospital, and meropenem and ceftriaxone were administered. The patient's condition deteriorated and he was transferred to a second hospital. On physical examination, a black scab was found and scrub typhus was suspected. Despite intensive treatment, the patient died on the fifth day. High levels of O. tsutsugamushi IgM antibody were confirmed. An autopsy revealed systemic vasculitis and perivasculitis. The endothelial tissue of the white pulp of the spleen was markedly infiltrated by plasma cells. The authors speculated that a severe immune reaction against O. tsutsugamushi enhanced an inflammatory response, leading to DIC. This case is a warning to doctors who are not familiar with scrub typhus.

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

PURPOSE: In 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. METHODS: The 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. RESULTS: There 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. CONCLUSION: Patients 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.