Carbazochrome sodium sulfonate and tranexamic acid combination therapy to reduce blood transfusions after 24 h of injury: A retrospective study.

Aim: Reducing the blood transfusion volume is important in severe trauma. We hypothesized that carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) would reduce blood transfusions in severe trauma. Methods: From April 2017 to March 2023, data were collected from patients (aged ≥16 years) admitted to our hospital for trauma and administered packed red blood cells (pRBC) and plasma transfusions within 12 h postinjury. Patients infused with CSS and TXA (CSS + TXA group) were compared with those infused with TXA alone (TXA group). The outcomes were blood product transfusion volumes within and after 24 h, the number of patients receiving >6 units of pRBC transfusion after 24 h, duration of intensive care unit and in-hospital stays, and 28-day in-hospital mortality. Results: In total, 138 patients were included in the study. In the univariate analyses, the CSS + TXA group (n = 62) showed a significant reduction in the total pRBC transfusion volume, in-hospital days, and number of patients receiving >6 units of pRBCs in the delayed phase. Based on the multivariate logistics regression analysis, only the CSS + TXA group had a significantly lower adjusted odds ratio for receiving >6 units of pRBC transfusion after 24 h. During the in-hospital days, the CSS + TXA group did not experience an increased incidence of major complications when compared with the TXA group. Conclusion: In patients with trauma, treatment with CSS with TXA may reduce the requirement for blood transfusion after 24 h. Moreover, this treatment can improve admission outcomes without increasing complications.

Survey of trauma patients injured by falling or flying objects in Japan based on the Japan Trauma Data Bank.

PURPOSE: We retrospectively investigated patients injured by falling/flying objects using the Japan Trauma Data Bank (JTDB). METHODS: The study collected information of the JTEB from January 2004 to May 2019. The subjects were divided into two groups: the unexpected accident (UA) group included cases in which the patient was injured by an unexpected accident; the labor accident (LA) group included cases in which the patient was injured at work. RESULTS: A total of 1997 patients were enrolled as subjects (UA group, n = 383; LA group, n = 1134). In both groups, head injuries were the most frequent type of injury, followed by chest injuries. The median head abbreviated injury scale of the UA group was significantly higher than that of the LA group. In the UA group, the percentage of female patients, average age, and average TRISS value were significantly greater in comparison to the LA group. The frequency of emergency operations in the UA group was significantly lower in comparison to the LA group. The frequency of head injuries in the UA group was significantly greater than that in the LA group. The frequencies of upper extremity and lower extremity injuries in the UA group were significantly lower than those in the LA group. CONCLUSION: This is the first report to analyze trauma patients injured by falling/flying objects using the JTDB. Public health and emergency providers can use this information to anticipate the health-care needs after falling/flying object injuries.

The effect of prehospital intravenous access in traumatic shock: a Japanese nationwide cohort study.

AIM: We aimed to evaluate effect of prehospital intravenous (IV) access on mortality in traumatic shock using a large nationwide dataset. METHODS: We used the Japan Trauma Data Bank to identify adults (≥18 years) with a systolic blood pressure <90 mm Hg at the trauma scene and were directly transported to the hospital between 2010 and 2019. We compared patients who had prehospital IV access (IV (+)) or not (IV (-)), using propensity score-matched analysis, and 1:1 nearest-neighbor matching without replacement. Standardized mean difference was used to evaluate the match balance between the two matched groups; a standardized mean difference >0.1 was considered a significant imbalance. Primary outcome was 72-h mortality. RESULTS: Propensity scores matching generated 479 pairs from 5,857 patients. No significant between group differences occurred in 72-h mortality (7.8 versus 8.8%; difference, -1.0%; 95% confidence interval [CI]: -2.5-4.5%), 28-day mortality (11.8 versus 11.3%; 95% CI: -4.6-3.6%), blood transfusion administration within 24 h (55.3 versus 49.1%; 95% CI: -0.1-12.6%), prehospital time (56.3 versus 53.0 min; 95% CI: -1.8-8.4 min), and cardiopulmonary arrest on hospital arrival (1.3 versus 1.3%; 95% CI: -1.4-1.4%). However, significantly higher systolic blood pressure on hospital arrival was found in the IV (+) than in the IV (-) group (104.6 versus 100.1 mm Hg; 95% CI: 0.3-8.7 mm Hg). CONCLUSION: We found no significant effect of establishing IV access in the prehospital setting on survival outcomes of patients with traumatic shock.

Experience using a portable X-ray system at the scene transported by a physician-staffed helicopter.

BACKGROUND: Fujifilm (Tokyo, Japan) developed a portable X-ray system called the CALNEO Xair, which can be carried by a physician. The X-ray radiation machine weighs 3.5 kg. The dimensions are: height, 144 mm; length, 148 mm; width, 258 mm. CASE PRESENTATION: When a 33-year-old woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. Staff of the doctor helicopter checked her at the scene, and the findings of chest and pelvic X-ray were all negative. She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance. CONCLUSION: This is the first report of a case evaluated by a portable X-ray system at the scene, under transportation by a doctor helicopter. This system could be useful for undertaking prehospital assessment and medical treatment.

An analysis of reports concerning overdose evaluated by abdominal computed tomography.

Recently, there have been a number of reports concerning the utility of abdominal computed tomography (CT) for diagnosing overdose (OD). We herein report the summary and results of an analysis of these reports to assess the significance of CT for patients with OD. Searches of Ichushi (Japana Centra Revuo Medicine) and PubMed were carried out to identify articles from 1983 to 2019 using the key words "poisoning" and "abdominal computed tomography". Forty-eight cases across 15 articles were defined as subjects in this report. The average age of subjects was 46 years old, and there were 28 women. Forty-five of the 48 subjects (93.8%) had positive findings of residual drugs on CT. The finding of a high-density fluid level in the stomach was the most frequent (60.4%), followed by ill-defined high-density material in the stomach (12.5%) and high-density tablets in the stomach (10.4%). One prospective study suggested the merits of decontamination for patients with positive findings on CT even if more than 60 min had elapsed since the ingestion of drugs. Computed tomography could aid in the diagnosis of OD in comatose patients who cannot talk or who present without any other evidence of OD. In addition, a recent study revealed the merits of decontamination for patients with positive findings on the CT even if more than 60 min had elapsed since the ingestion of drugs.

Massive intraperitoneal free air induced by pneumothorax and pneumomediastinum.

INTRODUCTION: Pneumoperitoneum (PP), or air within the abdominal cavity, is frequently a harbinger of serious abdominal pathology and often represents visceral perforation. We herein report a case of combined massive intraperitoneal free air, pneumothorax and pneumomediastinum but emergency laparotomy was negative. PRESENTATION OF CASE: A sixty-seven-year-old man was found unconscious on a road after being hit by a car. On arrival, he showed swelling of the head and flail chest. Computed tomography (CT) demonstrated cerebral contusion, multiple bilateral rib fractures, minute subcutaneous emphysema and a left hemothorax. As his consciousness and respiratory function deteriorated, tracheal intubation with mechanical ventilation with positive end-expiratory pressure was executed on the second day. On the third day, the CT scan revealed the new appearance of pneumomediastinum and massive free air in his intraperitoneal space. Emergency laparotomy was negative. DISCUSSION: The 'air leak' phenomenon, in which an alveolar air cell ruptures into the perivascular and peribronchial interstitial tissues, is a well-recognized consequence of positive end-expiratory pressure therapy. Accordingly, the deterioration of traumatic pneumothorax and/or the occurrence of pneumomediastinum after mechanical ventilation was the most likely cause of the PP in the present case. However, it remains possible that a minute unrecognized diaphragmatic injury caused the massive PP in the present case. CONCLUSION: We herein described a case of PP that occurred after mechanical ventilation in a patient with multiple injuries, but which did not originate from perforation of the gastrointestinal tract. It is most likely that the PP had an intrathoracic cause.

A system of delivering medical staff members by helicopter to manage severely wounded patients in an area where medical resources are limited.

Aim: We review the case of a severely injured patient to evaluate the system of delivering medical staff by helicopter in areas with limited medical resources. Methods: The patient's chart was reviewed, summarized, and presented. Results: A 22-year-old woman attempted a suicidal fall after using a knife to stab herself. She was transported to a local hospital. A radiological study revealed fractures to the patient's face and the base of her skull, pneumocephalus, traumatic subarachnoid hemorrhage, stab wounds to the neck and chest, pneumothorax, unstable pelvic fracture, and right femoral shaft fracture. Her circulation status became unstable. We sent medical staff members to the local hospital by doctor helicopter. The patient underwent tracheal intubation and the insertion of a chest drain, and was evacuated by doctor helicopter. After aggressive intensive treatments in our hospital, the patient finally obtained social rehabilitation. Conclusion: In an area where medical resources are limited, sending trained physicians to a referring hospital to appropriately prepare a severely wounded patient for transportation might be the key for the patient to maximize his or her chance of survival.

Cardiac arrest at high elevation with a favorable outcome.

A 36-year-old man started to climb Mount Fuji (3776m above sea level: ASL), from the Gotemba new fifth station (2400m ASL). He had no significant medical history, and this was his first attempt to climb such a high mountain. He began feeling chest discomfort but continued to climb. When he reached the ninth station of the mountain (3600mASL), he lost consciousness. One individual immediately provided basic life support using an automated external defibrillator (AED) that was located in the station. After electroshocks, he regained consciousness. He was transported to the fifth station, where an ambulance could approach, in a large crawler. When the medical staff, who were transported via helicopter and ambulance, examined him near the fifth station, he still complained of chest discomfort. A single spray of nitroglycerin and aspirin (200mg) was administered. He was transported to the Cardiac Care Unit via ambulance and helicopter under escort by a physician. A chest computed tomography angiogram indicated triple-vessel disease. He was discharged without any neurological deficits after undergoing bypass surgery. In high mountains that can be easily accessed by amateur climbers who may have cardiac disease, the placement of AED devices and the establishment of the chain of survival from the scene to the intensive care unit are essential for obtaining a favorable outcome when a climber suffers cardiac arrest.

Horse kick injury mimicking a handle bar injury or a hidden speared injury.

A 16-year-old male was transported to our emergency department after he was kicked in the abdomen by a horse. He was diagnosed with injury of the liver and abdominal rectus muscle, and was cured by observational treatment. An Ichushi search was undertaken to identify articles published from 1983 to 2013 using the key words "horse" and "trauma". We found 13 cases that described horse-related injuries and summarized these cases, including our case. There were 10 males, three females and one patient of an undescribed sex. The patients ranged in age from 16 to 58 years old, with an average age of 33 years. The injured sites were predominantly the face (mandible) and upper abdomen, indicating that a projecting part of the body may be more likely to be injured. Cardiac rupture, aortic head injury, or lethality induced by a horse kick have not been reported in Japan, but such injuries have been reported in other countries. Ten of 15 cases (67%) required surgical treatment for severe injuries. Horse kick injuries tend to be severe, because the transfer of energy from the end of the hoof, with a small cross-sectional area, to a small field, leads to internal organic injuries that are more severe than predicted, similar to a handlebar injury. Accordingly, we advocate the close observation of patients with horse kick injuries, which may be regarded as being similar to blunt stab wounds or hidden speared injuries.

Characteristics of patients who fell into open drains: a report from a single emergency center in East Shizuoka: Epidemiology of patients who fell into open drains in East Shizuoka.

Aim: To clarify the characteristics of injuries caused by falling into an open drain. Methods: A medical chart review was retrospectively carried out of all patients in East Shizuoka, Japan, who were injured due to falling into an open drain, and who were subsequently transported to hospital by ambulance or a physician-staffed helicopter, between January 2013 and December 2014. The patients were divided into two groups, those treated as outpatients and those who were admitted to hospital. Results: During the investigation period, there were 33 patients who had accidentally fallen into an open drain. The ages of the subjects ranged from 10 to 90 years, with an average age of 58.8 years. The average age of the subjects, the ratio of female patients, and the average injury severity score in the admission group were higher than that of the outpatient group. One patient in the admission group who had cardiac arrest due to a cervical cord injury eventually died. Conclusion: Falls into open drains are especially frequent in elderly people and female patients, and older patients tend to more frequently require admission due to severe injury. To prevent injuries of this type, some measures are required to improve the safety of open drains.

A case of the vacuum phenomenon as a mechanism of gas production in the abdominal wall.

A 40-year-old man experienced a collision with a car while driving a motorcycle in which the car was in the opposite lane and made a right turn. The patient was thrown approximately 10 m from the point of collision and, as he exhibited a consciousness disturbance, was transferred to our department. He had a score of 13 on the Glasgow Coma Scale with sinus tachycardia on arrival. He showed guarding of the abdomen. A pan scan disclosed traumatic subarachnoid hemorrhage, intraventricular hemorrhage, fractures of the atlas, thoracic spine, sternum and left femur, and gas in the abdomen located just in front of the stomach. As the gas in the abdomen was initially judged to be free air, the patient underwent emergency laparotomy. However, no signs of perforation or injury were detected throughout the entire digestive tract. The accumulation of minute gas (vacuum phenomenon) occurs as traumatic impact. As representative mimics of free air were not observed during surgery in the present case, we believe that the traumatic impact to the patient's abdomen as a result of the collision caused the accumulation of gas in the abdominal wall due to vacuum phenomenon. Physicians should be aware of this clinical entity to accurately recognize the mechanism of gas formation in patients showing negative laparotomy findings for gas in the abdomen. This unique case adds additional information regarding the documented etiologies of mimics of pneumoperitoneum.

A case of thalamic hemorrhage with takotsubo cardiomyopathy.

CASE: A 76-year-old woman was found unconscious by her family. She had suffered a fall and was soaked in kerosene. On arrival at our emergency department, she was unconscious, normotensive, with right hemiplegia and chemical burns. A computed tomographic scan of her head indicated left thalamic hemorrhage. An electrocardiogram showed ST elevation at the precardial leads. An echocardiogram revealed characteristic of takotsubo cardiomyopathy. OUTCOME: The patient was intubated and treated conservatively. She was transferred to another hospital for rehabilitation after complete epithelization of the chemical burn. This is the second reported case of thalamic hemorrhage with takotsubo cardiomyopathy. The thalamic hemorrhage might have induced autonomic disturbances and caused the takotsubo cardiomyopathy in this case. CONCLUSION: Physicians should pay attention to the potential complication of takotsubo cardiomyopathy, which may affect cardiopulmonary function even when patients are being treated for intracerebral hemorrhage.

Importance of smoking and the occurrence of acute poisoning due to waterproof spray.

A search of the database Ichushi (Japana Centra Revuo Medicana), which collects summaries of Japanese medical articles, was undertaken to identify articles published between 1983 and 2013, using the key word "waterproof". There was one original article and 19 case reports describing acute poisoning due to inhalation of waterproof spray gas, and providing information about the patient's smoking habit. Twenty-three of the 25 cases (92% of male patients, 71% of female patients) had a smoking habit. The one female case who did not have a smoking habit was in an environment exposed to secondhand smoke, because her husband had smoking habit. All cases had respiratory symptoms, and 24 cases had lung edema confirmed by computed tomography. There were no fatal cases among these patients. The one original article reported that 93% of males and 49% of females among a total of 104 cases with acute poisoning due to inhalation of waterproof spray gas had a smoking habit. Accordingly, people with a smoking habit tend to be vulnerable to exposure to waterproof spray gas.