Acute Mesenteric Ischemia Secondary to Candida Endocarditis: A Case Report.

A 36-year-old man presented with abdominal pain, vomiting, and diarrhea. On arrival, his vital signs were remarkable for fever (39.3 °C) and tachycardia (127 beats/min, regular). His abdomen was distended, and a blood test showed elevations of inflammatory markers. Contrast-enhanced computed tomography revealed a superior mesenteric artery thrombus, ischemic colitis, ascites, and infarctions in the spleen and right kidney. He was diagnosed with bowel necrosis due to acute mesenteric ischemia (AMI). An emergent laparotomy was performed. The following day, Candida tropicalis was identified in the blood culture. In addition, transthoracic echocardiography revealed vegetation on the mitral valve leaflet. These findings were suggestive of infective endocarditis (IE) caused by C. tropicalis (Candida endocarditis); thus, the patient underwent surgical mitral valve replacement with the administration of antifungal therapy. Following postoperative intensive care and a prolonged course of antifungal treatment, he achieved a full recovery. AMI is only rarely caused by IE, and this case is the first reported instance of AMI secondary to Candida endocarditis. When encountering patients with AMI without any risk factors for thromboembolism, clinicians should be aware that IE may cause AMI.

Cardiac arrest with retropharyngeal hematoma caused by minor facial injuries from a ground level fall.

Background: Traumatic retropharyngeal hematoma followed by airway obstruction is extremely rare. In this report, we show unique images from two cases of out-of-hospital cardiac arrest due to airway obstruction caused by massive retropharyngeal hematoma after a minor facial injury. Case presentation: Case 1: A 78-year-old man was transferred to our emergency department due to cardiac arrest. He presented with respiratory insufficiency after a ground level fall. His neck was swollen, and the attending physician performed an emergent cricothyroidotomy to secure his airway and administered intravenous adrenaline. Computed tomography revealed a massive retropharyngeal hematoma and severe hypoxic encephalopathy. Despite a temporary return of spontaneous circulation (ROSC), the patient died on the admission day.Case 2: A 68-year-old woman presented with dyspnea, prompting her family to call an ambulance. On the way to the hospital, the ambulance crew determined the patient was in cardiac arrest. The patient's history revealed a ground level fall in which she hit her face. Computed tomography revealed a massive retropharyngeal hematoma compressing her upper airway. Although ROSC was obtained, the patient died on the 12th day of hospitalization due to hypoxic encephalopathy.Extension views of cervical spine images identified angular instability without cervical bone fracture in both cases, suggesting that possible injuries of the anterior longitudinal ligament contributed to the retropharyngeal hematoma. Conclusions: Patients presenting with asphyxia after a simple ground level fall accompanied by minor facial injuries should be assessed by emergency physicians for the possibility of a retropharyngeal hematoma. In both cases presented here, unique images indicate possible injuries of the anterior longitudinal ligament.

Delayed Tension Hemothorax With Nondisplaced Rib Fractures After Blunt Thoracic Trauma.

Blunt thoracic trauma often causes rib fractures, hemothorax, and pneumothorax. Although there is no established definition regarding the duration and management of delayed hemothorax, it commonly occurs in a few days and exhibits at least one displaced rib fracture. Moreover, delayed hemothorax rarely develops tension hemothorax. A 58-year-old male who had a motorcycle accident received conservative treatment from his orthopedic doctor. He felt a sudden severe chest pain 19 days after the accident. Contrast-enhanced computed tomography (CT) of the chest revealed multiple left-sided rib fractures without displacement, left pleural effusion, and extravasation near the intercostal space of the seventh rib fracture. After transfer to our hospital and a plain CT scan, which showed a more mediastinal shift toward the right, his condition deteriorated with cardiorespiratory embarrassment, such as restlessness, hypotension, and neck vein distention. We diagnosed him with obstructive shock due to tension hemothorax. Immediate chest drainage ameliorated restlessness and elevated blood pressure. Here, we report an extremely rare and atypical case of delayed tension hemothorax after blunt thoracic trauma without displaced rib fractures.

PCO2 on arrival as a predictive biomarker in patients with out-of-hospital cardiac arrest.

BACKGROUND: Treating patients with out-of-hospital cardiac arrest (OHCA) requires early prediction of outcome, ideally on hospital arrival, as it can inform the clinical decisions involved. This study evaluated whether partial pressure of carbon dioxide (PCO2) on arrival is associated with outcome at one month OHCA patients. METHODS: This was a single-center retrospective study of adult OHCA patients treated between January 2016 and December 2020. Outcomes were defined along the Cerebral Performance Category (CPC) scale. Primary outcome was mortality (CPC 5) at one month. Secondary outcomes were death or unfavorable neurological outcome (CPC 3-5) and unfavorable neurological outcome (CPC 3-4) at one month. Multivariable analysis was adjusted for age, sex, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, initial shockable rhythm, and time from call to emergency medical services to hospital arrival. RESULTS: Out of 977 OHCA patients in the study period, 19 were excluded because they were aged under 18 years, 79 because they underwent extracorporeal cardiopulmonary resuscitation, and 101 due to lack of PCO2 data. This study included 778 patients total; mortality (CPC 5) at one month was observed in 706 (90.7%), death or unfavorable neurological outcome (CPC 3-5) in 743 (95.5%), and unfavorable neurological outcome (CPC 3-4) in 37 (4.8%). In multivariable analysis, high PCO2 levels showed significant association with mortality (CPC 5) at one month (odds ratio [OR] [per 5 mmHg], 1.14; 95% confidence interval [CI], 1.08-1.21), death or unfavorable neurological outcome (CPC 3-5) (OR [per 5 mmHg], 1.29; 95% CI, 1.17-1.42), and unfavorable neurological outcome (CPC 3-4) (OR [per 5 mmHg], 1.21; 95% CI, 1.04-1.41). CONCLUSIONS: High PCO2 on arrival was significantly associated with mortality and unfavorable neurological outcome in OHCA patients.

Long-term outcomes and prognostic factors of extracorporeal cardiopulmonary resuscitation in patients older than 75 years: a single-centre retrospective study.

BACKGROUND: Few studies have assessed older adult patients who received extracorporeal cardiopulmonary resuscitation (ECPR) after cardiac arrest, and outcomes and prognostic factors of ECPR in this population remain unclear. This study aimed to assess the long-term outcomes and prognostic factors among patients older than 75 years who received ECPR after experiencing cardiac arrest. METHODS: This is a single-centre, retrospective case-control study conducted between August 2010 and July 2019. Consecutive patients older than 75 years who had in-hospital (IHCA) or out-of-hospital cardiac arrest (OHCA) and received ECPR at the Emergency Department in the Hyogo Emergency Medical Center, Hyogo, Japan, were included. The primary outcome was a favourable neurological outcome, defined as a Cerebral Performance Category score of 1-2 at 1 year after the event. Univariate logistic regression was used to determine the association between variables and patient outcomes. RESULTS: Of the 187 patients with cardiac arrest who received ECPR, 30 were older than 75 years and 28 (15% of the cohort receiving ECPR) were examined in this study. The median age of the patients was 79 years (IQR 77-82), and there were 13 (46%) male patients. Neurological outcomes were favourable for seven (25%) patients, five of whom had IHCA and two with out-of-hospital OHCA. On univariate analysis, patients with a favourable outcome had a shorter median total collapse time (TCT) than those with an unfavourable outcome (favourable: 18.0 min (IQR 13.0-33.5) vs unfavourable: 44.0 min (IQR 25.0-53.0); p=0.049). CONCLUSION: In selected patients older than 75 years, ECPR could be beneficial by providing a shorter TCT, which may contribute to favourable neurological outcomes. Nevertheless, further studies are needed to validate these findings.

Holospinal epidural abscess caused by Streptococcus anginosus group: a literature review.

Spinal epidural abscess (SEA) usually extends over three to four vertebrae. We present a case of holospinal epidural abscess (HEA) caused by the Streptococcus anginosus group (SAG). A man in his 40s with a 2-week history of fever, back pain, and progressive tetraparesis was referred to us from the local hospital. MRI showed epidural fluid collection from C2 to S1. Blood and pus cultures revealed the presence of SAG. He was treated by emergency laminoplasty, epidural drainage and antibiotic treatment. After the 111st hospital day, his manual muscle test was shown to improve; hence, he was transferred for rehabilitation. According to the previous reports, we identified 12 cases of SEA extending from the cervical spine to the sacrum, including our case. For one-fourth of these cases, SAG was the causative organism of this rare SEA. Therefore, SAG should be considered causative organisms in HEA.

A novel extracorporeal cardiopulmonary resuscitation strategy using a hybrid emergency room for patients with pulseless electrical activity.

BACKGROUND: Whether extracorporeal cardiopulmonary resuscitation (ECPR) is indicated for patients with pulseless electrical activity (PEA) remains unclear. Pulmonary embolism with PEA is a good candidate for ECPR; however, PEA can sometimes include an aortic disease and intracranial haemorrhage, with extremely poor neurological outcomes, and can thus not be used as a suitable candidate. We began employing an ECPR strategy that utilised a hybrid emergency room (ER) to perform computed tomography (CT) before extracorporeal membrane oxygenation (ECMO) induction from January 2020. Therefore, the present study aimed to evaluate the effectiveness of this ECPR strategy. METHODS: Medical records of patients who transferred to our hybrid ER and required ECPR for PEA between January 2020 and November 2021 were reviewed. RESULTS: Twelve consecutive patients (median age, 67 [range, 57-73] years) with PEA requiring ECPR were identified in our hybrid ER. Among these patients, nine were diagnosed using an initial CT scan (intracranial haemorrhage (3); cardiac tamponade due to aortic dissection (3); aortic rupture (2); and cardiac rupture (1)), and unnecessary ECMO was avoided. The remaining three patients underwent ECPR, and two of them survived with favourable neurological outcomes. Patients not indicated for ECPR were excluded before ECMO induction. CONCLUSION: Our ECPR strategy that involved the utilisation of a hybrid ER may be useful for the exclusion of patients with PEA not indicated for ECPR and decision making.

Prehospital management of a non-intubated inhalation injury patient using transcutaneous monitoring of carbon dioxide.

A 46-year-old man experienced facial burns due to a fire in his house. In the prehospital setting, suspecting inhalation injury and carbon monoxide poisoning, an emergency physician decided to bring him to the hospital for carbon dioxide (CO2) monitoring without endotracheal intubation for approximately 20 min because of less severe respiratory distress. On the way to the hospital, the patient's end-tidal CO2 monitoring ranged from 19 to 30 mm Hg, and transcutaneous carbon dioxide (TcPCO2) remained between 50 and 55 mm Hg. On arrival at the hospital, PaCO2 showed 51.6 mm Hg. Endotracheal intubation using a bronchoscope was performed in the emergency room, and inhalation injury was observed. He was extubated on day 5 and discharged on day 10. In the prehospital setting, TcPCO2 monitoring is useful for initial management of non-intubated inhalation injury patients even with high concentration oxygen.

Retro-odontoid pseudotumor with uncommon presentation of cervical spine injury.

BACKGROUND: We report the first case of retro-odontoid pseudotumor with an isolated symptom of C2-C3 dysesthesia triggered by a traumatic event. CASE PRESENTATION: An 86-year-old man, who was a wood craftsman for more than 50 years, presented to the emergency room with sudden-onset severe posterior head and neck dysesthesia after accidentally falling backward. No neurological impairment of the extremities was noted. Computed tomography revealed a C2-C7 osteophyte formation, mainly in front of the vertebral bodies. Moreover, magnetic resonance imaging showed cervical spinal cord compression by a soft tissue mass posterior to the odontoid process of the axis. Therefore, we diagnosed a cervical spine injury with an isolated symptom of C2-C3 dysesthesia due to a retro-odontoid pseudotumor. He did not undergo surgical intervention and was transferred to a rehabilitation hospital on day 11 for pain control. CONCLUSION: Our report could be useful to emergency physicians dealing with similar cases of cervical symptoms following trauma.

Use of hyperbaric oxygen therapy for preventing delayed neurological sequelae in patients with carbon monoxide poisoning: A multicenter, prospective, observational study in Japan.

BACKGROUND: The purpose of this study was to clarify the practical clinical treatment for acute carbon monoxide (CO) poisoning in Japan and to investigate the efficacy of hyperbaric oxygen (HBO2) therapy in preventing delayed neurological sequelae (DNS) in the acute phase of CO poisoning. METHODS: We conducted a multicenter, prospective, observational study of acute CO poisoning in Japan. Patients with acute CO poisoning were enrolled and their treatment details were recorded. The primary endpoint was the onset of DNS within 2 months of CO exposure. Factors associated with DNS were assessed with logistic regression analysis. RESULTS: A total of 311 patients from 57 institutions were registered and 255 were analyzed: 171 received HBO2 therapy (HBO2 group) and 84 did not (normobaric oxygen [NBO2] group). HBO2 therapy was performed zero, once, twice, or three times within the first 24 h in 1.8%, 55.9%, 30.9%, and 11.3% of the HBO2 group, respectively. The treatment pressure in the first HBO2 session was 2.8 ATA (47.9% of the HBO2 group), 2.0 ATA (41.8%), 2.5 ATA (7.9%), or another pressure (2.4%). The incidence of DNS was 13/171 (7.6%) in the HBO2 group and 3/84 (3.6%) in the NBO2 group (P = 0.212). The number of HBO2 sessions in the first 24 h was one of the factors associated with the incidence of DNS (odds ratio, 2.082; 95% confidence interval, 1.101-3.937; P = 0.024). CONCLUSIONS: The practical clinical treatment for acute CO poisoning, including HBO2 therapy, varied among the institutions participating in Japan. HBO2 therapy with inconsistent protocols showed no advantage over NBO2 therapy in preventing DNS. Multiple HBO2 sessions was associated with the incidence of DNS.

Pitfall of left sided triple-lumen catheter for continuous renal replacement therapy: A case report.

We report a case of vascular injury caused by a multi-lumen catheter for CRRT inserted through left jugular vein. Diagnosis was delayed because CRRT could be continued. Clinicians should be aware of potential vascular complications associated with the wrong placement of multi-lumen catheters even if blood flow continues without difficulty.

Acute Type A Aortic Dissection With Cardiopulmonary Arrest at Presentation.

BACKGROUND: Management of acute type A aortic dissection (AADA) presenting with cardiopulmonary arrest (CPA) may require aggressive cardiopulmonary resuscitation (CPR), including extracorporeal CPR followed by aortic repair. This study evaluated the early and long-term outcomes of patients with preoperative CPA related to AADA. METHODS: Between September 2003 and August 2019, 474 patients with AADA were brought to our hospital, 157 (33.1%) presenting with CPA. Their mean age was 74.3 ± 11.3 years and prevalence of out-of-hospital CPA 90%, and causes of CPA were cardiac tamponade in 75%, hemothorax in 10%, and coronary malperfusion in 10% of cases. In the same time periods 2974 patients with CPA were transported, and AADA was 4.8% of all cause of CPA. RESULTS: Return of spontaneous circulation was achieved in 26 patients (17%) and extracorporeal CPR was required in 31 (20%); 131 CPA patients (83%) died before surgery, 24 (15%) underwent aortic repair, and 2 (1%) received nonsurgical care. Hospital mortality was 90%, and none survived without aortic repair. Of patients achieving return of spontaneous circulation 17 underwent aortic repair, 13 survived, and 5 fully recovered. All patients with extracorporeal CPR died: 24 before surgery and 7 postoperatively. There were significant differences in hospital mortality between patients who did and did not undergo aortic repair (P < .01). Aortic repair was the only significant predictor of long-term survival (P < .01). CONCLUSIONS: AADA with CPA is associated with significantly high mortality; however aortic repair can be performed with a 30% likelihood of functional recovery, if return of spontaneous circulation is achieved. Preoperative extracorporeal membrane oxygenation is not recommended in this patient cohort.

Therapeutic efficacy for traumatic asphyxia with a focus on cardiac arrest.

AIM: To investigate the clinical features of traumatic asphyxia, specifically the presence of cardiac arrest and therapeutic efficacy. This review will be useful for future emergencies. METHODS: Sixteen traumatic asphyxia cases from our hospital between April 2007 and March 2019 were reviewed and divided into three groups: those experiencing cardiac arrest at the time of rescue (group A, six cases), those experiencing cardiac arrest after rescue (group B, five cases), and those who did not experience cardiac arrest (group C, five cases). RESULTS: All cases had abnormal findings in the skin or conjunctiva. The total mortality rate reached 56%. Among the 11 cases in groups A and B that resulted in cardiac arrest, 10 had an Injury Severity Score of 16 or higher and an Abbreviated Injury Scale score in the chest of 3 or higher. The patients' injuries included pneumothorax, flail chest, and pericardial hematoma. The heartbeat was restarted in seven cases, and two cases completely recovered. CONCLUSION: In some traumatic asphyxia cases, the treatment course was relatively effective even with cardiac arrest; thus, life support efforts should not be spared in such cases.

Preoperative fluid restriction for trauma patients with hemorrhagic shock decreases ventilator days.

Aim: In recent years, with the concept of damage control resuscitation, hemostasis and preoperative fluid restriction have been carried out, but there is controversy regarding the effectiveness of fluid restriction. Methods: From April 2007 to March 2013, 101 trauma patients presented with hemorrhagic shock (systolic blood pressure ≤90 mmHg) at the prehospital or emergency department and were admitted to Hyogo Emergency Medical Center (Hyogo, Japan). They underwent emergency hemostasis by surgery and transcatheter arterial embolization. We compared two groups in a historical cohort study, the aggressive fluid resuscitation (AR) group, which included 59 cases treated in the period April 2007-March 2010, and the fluid restriction (FR) group, which included 42 cases treated in the period April 2010-March 2013. Results: There was no difference between both groups in patient background (heart rate, 110 b.p.m.; systolic blood pressure, 70 mmHg). The Injury Severity Score was 34 (AR) versus 38 (FR) (not significant). Preoperative infusion volume of crystalloid significantly decreased, from 2310 mL (AR) to 1025 mL (FR) (P ≤ 0.01). There was no difference in mortality (36% [AR] versus 41% [FR]). Ventilator days significantly decreased, from 8.5 days (AR) to 5.5 days (FR) (P = 0.02). Conclusions: Preoperative fluid restriction for trauma patients with hemorrhagic shock did not improve mortality, but it decreased ventilator days by reducing the perioperative plus water balance and it might contribute to perioperative intensive care.

Heart failure complicating with SAPHO syndrome.

A 65-year-old man was referred to our hospital with dyspnoea due to acute heart failure. He presented with swelling in the left clavicle and pustulosis on both soles. An antihypertensive drug and non-invasive positive pressure ventilation improved his condition rapidly. Since all his physical symptoms were compatible with the criteria of SAPHO (synovitis, acne, pustulosis, hyperostosis, osteomyelitis) syndrome, we suspected that the SAPHO syndrome might cause acute heart failure. The aetiology between SAPHO syndrome and heart failure is unclear. Further studies are needed to clarify their relationship.