ABSTRACT
Basic life support (BLS) courses for laypersons, including cardiopulmonary resuscitation (CPR) training, is known to improve outcomes of out-of-hospital cardiac events. We asked medical students to provide BLS training for laypersons as a part of their emergency medicine education and evaluated the effects of training on the BLS skills of laypersons. We also used a questionnaire to determine whether the medical students who provided the BLS training were themselves more confident and motivated to perform BLS compared to students who did not provide BLS training. The proportions of laypersons who reported confidence in checking for a response, performing chest compressions, and automated external defibrillator (AED) use were significantly increased after the BLS training. The proportions of medical students who reported increased confidence/motivation in terms of understanding BLS, checking for a response, chest compression, use of AED, and willingness to perform BLS were significantly greater among medical students who provided BLS instructions compared to those who did not. BLS instruction by medical students was associated with an improvement in laypersons' CPR accuracy and confidence in responding to cardiac arrest. The results indicate that medical students could gain understanding, confidence, and motivation in regard to their BLS skills by teaching BLS to laypersons.
Subject(s)
Heart Arrest , Students, Medical , HumansABSTRACT
Traumatic eyeball luxation is a rare clinical condition with a dramatic presentation. Here, we describe a unique case of traumatic globe luxation and complete optic nerve transection caused by heavy object compression. A 45-year-old male automobile mechanic was injured when a truck slipped from its supports, crushing his head and face. On arrival, his right eyeball was obviously displaced anteriorly and he had no light perception. Computed tomography revealed complex frontal bone and facial fractures with underlying brain contusion in addition to complete transection of the right optic nerve. The patient was successfully treated using a multidisciplinary approach.
Subject(s)
Eye Injuries/pathology , Eye Injuries/surgery , Facial Bones/pathology , Fractures, Bone/surgery , Optic Nerve Injuries/pathology , Accidents, Occupational , Eye Enucleation , Facial Bones/surgery , Fractures, Bone/pathology , Frontal Bone/pathology , Frontal Bone/surgery , Humans , Male , Middle AgedABSTRACT
The primary toxicity of hydrogen peroxide results from its interaction with catalase, which liberates water and oxygen. We report the case of a 14-year-old Japanese girl with portal venous gas that was caused by oxygen liberated from intentionally ingested hydrogen peroxide. Although she had a past history of atrial septal defect, recovery without cardiac or neurological sequelae was achieved using hyperbaric oxygen therapy. Emergency physicians must be aware of the danger of liberated oxygen due to hydrogen peroxide ingestion.
Subject(s)
Blood Gas Analysis , Hydrogen Peroxide/poisoning , Hyperbaric Oxygenation , Portal Vein , Adolescent , Female , Humans , Poisoning/therapyABSTRACT
A healthy 10-year-old boy vomited during sleep and later complained of abdominal pain; he became drowsy and uncommunicative. At the nearby hospital E.R., he deteriorated rapidly, and his respiratory movements were absent with cardiac arrest. He was immediately resuscitated. Brain MRI showed no abnormalities. EEG revealed an abnormal pattern with recurrent multifocal epileptiform activity over the bilateral occipital and frontal regions during sleep. Based on the clinical/radiological findings we diagnosed Panayiotopoulos syndrome (PS), a benign form of early-onset pediatric epilepsy characterized by autonomic symptoms. Lifethreating cardiopulmonary arrest is rare in PS, but long seizure duration of PS may associate with apnea and bradycardia.
Subject(s)
Heart Arrest/etiology , Myoclonic Epilepsy, Juvenile/complications , Status Epilepticus/complications , Child , Electroencephalography , Humans , Male , Vomiting/etiologyABSTRACT
Emphysematous cystitis is an uncommon acute infection of the underlying bladder musculature and mucosa, caused by gas-producing organisms. Here we describe an 87-year-old woman with diabetes mellitus and emphysematous cystitis who was successfully treated with hyperbaric oxygen (HBO2) therapy. Her predisposition of diabetes and infection with gas-producing bacteria was considered to precede the development of emphysematous cystitis. Computed tomography revealed gas accumulation in the bladder wall and lumen. Antibiotics and HBO2 therapy were administered. HBO2 therapy may be beneficial due to the improvement in oxygenation of the tissues affected by the disease. HBO2 is a useful adjunct therapy for the management of severe emphysematous cystitis.
Subject(s)
Cystitis/therapy , Emphysema/therapy , Hyperbaric Oxygenation/methods , Aged, 80 and over , Cystitis/diagnostic imaging , Diabetes Mellitus, Type 2/complications , Emphysema/diagnostic imaging , Female , Humans , Tomography, X-Ray Computed , Urinary Bladder/diagnostic imagingABSTRACT
Worldwide, hemorrhagic shock in major trauma remains a major potentially preventable cause of death. Controlling bleeding and subsequent coagulopathy is a big challenge. Immediate assessment of unidentified bleeding sources is essential in blunt trauma patients with hemorrhagic shock. Chest/pelvic X-ray in conjunction with ultrasonography have been established classically as initial diagnostic imaging modalities to identify the major sources of internal bleeding including intra-thoracic, intra-abdominal, or retroperitoneal hemorrhage related to pelvic fracture. Massive soft tissue injury, regardless of whether isolated or associated with multiple injuries, occasionally causes extensive hemorrhage and acute traumatic coagulopathy. Specific types of injuries, including soft tissue injury or retroperitoneal hemorrhage unrelated to pelvic fracture, can potentially be overlooked or be considered "occult" causes of bleeding because classical diagnostic imaging often cannot exclude such injuries. The purpose of this narrative review article is to describe "occult" or unusual sources of bleeding associated with blunt trauma.
Subject(s)
Hemorrhage/etiology , Wounds, Nonpenetrating/complications , Fractures, Bone/complications , Humans , Soft Tissue Injuries/complicationsABSTRACT
Background: The clinical impact of signs of life (SOLs) in traumatic cardiac arrest (TCA) remains to be elucidated. The aim of this study was to examine the association between SOLs and survival/neurological outcomes in TCA patients. Methods: Retrospective data from the Japan Trauma Data Bank (2019-2021) was reviewed. TCA patients were assigned to one of two study groups based on the presence or absence of SOLs and compared. SOLs were defined as having at least one of following criteria: pulseless electrical activity >40 beats per minute, gasping, positive light reflex, or extremity/eye movement at hospital arrival. The primary outcome was survival at hospital discharge. The secondary outcome was favorable neurological status (Glasgow Outcome Scale score of 4 or 5) at hospital discharge. Results: A total of 1,981 patients (114 with SOLs and 1,867 without SOLs) were included. Characteristics of patients were as follows: age (median age 60.0 years old [interquartile range: 41-80] years vs. 55.4 [38-75] years), gender (male: 76/114 (66.7%) vs. 1,207/1,867 (65.0%), blunt trauma (90/111 [81.1%] vs. 1,559/1,844 [84.5%]), Injury Severity Score (29.2 [22-41] vs. 27.9 [20-34]). Patients with SOLs showed higher survival (10/114 (8.8%) vs. 25/1,867 (1.3%), OR 1.96 [CI 1.20-2.72]) and higher favorable neurological outcomes (4/110 (3.5%) vs. 6/1,865 (0.3%), OR 2.42 [CI 1.14-3.70]) compared with patients without SOLs. Conclusions: TCA patients with SOLs at hospital arrival showed higher survival and favorable neurological outcomes at hospital discharge compared with TCA patients without SOLs.
ABSTRACT
BACKGROUND: Gray-to-white matter ratio (GWR), measured by computed tomography (CT), is commonly used to predict poor neurological outcomes after out-of-hospital cardiac arrest (OHCA). The prognostic performance of GWR in OHCA patients receiving extracorporeal cardiopulmonary resuscitation (ECPR) is not known. METHODS: This study is a secondary analysis of data from the SAVE-J II registry, a retrospective, multicenter study. Participants were divided into four groups according to average GWR (aGWR) values ranging from 1.00 to 1.39, separated by 0.1 intervals. The aGWR values were calculated for bilateral basal ganglia, centrum semiovale, and high convexity obtained by head CT within 24 h after ECPR. Primary outcome was poor neurological outcomes at 30-day. RESULTS: In total, 1,146 OHCA patients treated with ECPR were included in our analysis. Overall, participants with lower aGWR more likely had poor neurological outcomes, aGWR 1.00-1.09 (94.6%), aGWR 1.10-1-19 (87.8%), aGWR 1.20-1.29 (78.5%), and aGWR 1.30-1.39 (70.3%). Multivariable logistic regression showed that lower aGWR was associated with poor neurological outcome at 30-day, aGWR 1.30-1.39: reference, aGWR 1.00-1.09: adjusted odds ratio (aOR) 10.01 (95% confidence interval (CI) [3.58-27.99]), aGWR 1.10-1.19: aOR 4.83 (95% CI [2.31-10.12]), aGWR 1.20-1.29: aOR 2.16 (95% CI [1.02-4.55]). Receiver operating characteristic curve analysis revealed that the prognostic performance of aGWR had an area under the curve of 0.628, 95% CI [0.59-0.66]). The aGWR threshold of 1.005 for predicting poor neurological outcome reached 100% specificity with 0.1% sensitivity. CONCLUSION: Early neuro-prognostication depending on GWR may not be sufficient after ECPR and requires a multimodal approach.
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Background: Grey-white matter ratio (GWR) measured by head computed tomography (CT) scan is known as a neurological prognostication tool for out-of-hospital cardiac arrest (OHCA) survivors. The prognostic value of GWR obtained early (within two hours after return of spontaneous circulation [ROSC]) remains a matter of debate. Methods: We conducted a multicenter, retrospective, observational study at five hospitals. We included adult OHCA survivors who underwent head CT within two hours following ROSC. GWR values were measured using head CT. Average GWR values were calculated by the mean of the GWR-basal ganglia and GWR-Cerebrum. We divided the patients into poor or favorable neurological outcome groups defined by Glasgow-Pittsburgh Cerebral Performance Category scores. The predictive accuracy of GWR performance was assessed using the area under the curve (AUC). The sensitivities and specificities for predicting poor outcome were examined. Results: Of 377 eligible patients, 281 (74.5%) showed poor neurological outcomes at one month after ROSC. Average GWR values of the poor neurological outcome group were significantly lower than those of the favorable neurological outcome. The average GWR value to predict neurological outcome with Youden index was 1.24 with AUC of 0.799. When average GWR values were 1.15 or lower, poor neurological outcomes could be predicted with 100% specificity. Conclusions: GWR values measured by head CT scans early (within two hours after ROSC) demonstrated moderate predictive performance for overall ROSC patients. When limited to the patients with GWR values of 1.15 or lower, poor neurological outcomes could be predicted with high specificity.
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BACKGROUND: The appropriateness of a restrictive transfusion strategy for those with active bleeding after traumatic injury remains uncertain. Given the association between tissue hypoxia and lactate levels, we hypothesized that the optimal transfusion strategy may differ based on lactate levels. This post hoc analysis of the RESTRIC trial sought to investigate the association between transfusion strategies and patient outcomes based on initial lactate levels. METHODS: We performed a post hoc analysis of the RESTRIC trial, a cluster-randomized, crossover, non-inferiority multicenter trials, comparing a restrictive and liberal red blood cell transfusion strategy for adult trauma patients at risk of major bleeding. This was conducted during the initial phase of trauma resuscitation; from emergency department arrival up to 7 days after hospital admission or intensive care unit (ICU) discharge. Patients were grouped by lactate levels at emergency department arrival: low (< 2.5 mmol/L), middle (≥ 2.5 and < 4.0 mmol/L), and high (≥ 4.0 mmol/L). We compared 28 days mortality and ICU-free and ventilator-free days using multiple linear regression among groups. RESULTS: Of the 422 RESTRIC trial participants, 396 were analyzed, with low (n = 131), middle (n = 113), and high (n = 152) lactate. Across all lactate groups, 28 days mortality was similar between strategies. However, in the low lactate group, the restrictive approach correlated with more ICU-free (ß coefficient 3.16; 95% CI 0.45 to 5.86) and ventilator-free days (ß coefficient 2.72; 95% CI 0.18 to 5.26) compared to the liberal strategy. These findings persisted even after excluding patients with severe traumatic brain injury. CONCLUSIONS: Our results suggest that restrictive transfusion strategy might not have a significant impact on 28-day survival rates, regardless of lactate levels. However, the liberal transfusion strategy may lead to shorter ICU- and ventilator-free days for patients with low initial blood lactate levels.
Subject(s)
Blood Transfusion , Erythrocyte Transfusion , Adult , Humans , Erythrocyte Transfusion/adverse effects , Erythrocyte Transfusion/methods , Hospitalization , Intensive Care Units , Lactic AcidABSTRACT
Massive methanol exposure can lead to severe and detrimental effects that can result in death or brain death. As organs from patients with brain death after methanol ingestion are less likely to be recovered, these patients have been considered marginal donors. We present a case of successful multiple organ transplantation (heart, lungs, and kidneys) from a methanol-poisoned patient. Our experience illustrates that donor death from methanol intoxication does not preclude organ transplantation.
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Seat belts with shoulder restraints have decreased the frequency of life-threatening severe chest trauma caused by car accidents. However, the introduction of seat belt legislation has led to an increase in a specific pattern of blunt trauma known as seat belt syndrome, which includes rib, clavicle, spine, and sternum fractures, as well as rupture of hollow pelvic and abdominal viscera, mesenteric tears, and major vessel injuries. The shoulder restraint part of the three-point seat belt commonly rests near or over the female and male breast. A 54-year-old female presented to our emergency department complaining of swelling and pain in her left breast immediately after a traffic accident. The patient had used a seat belt with a shoulder restraint. Bruising was noted along her chest where there had been seat belt contact. Her breast hematoma was most likely caused by breast tissue compression between her rib and the seat belt. Contrast-enhanced computed tomography demonstrated a sizable breast hematoma with active arterial contrast material extravasation, as well as multiple left rib fractures. The patient was conservatively treated with analgesic and anti-inflammatory drugs. Complete resolution was achieved, and her breast returned to its normal appearance. Although endovascular treatment and surgical hemostasis have been proposed for the treatment of breast injuries with active bleeding, conservative treatment such as compression hemostasis may be feasible.
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Background: Myxedema coma is an extremely rare but fatal endocrine emergency that requires urgent recognition and treatment. We describe a case of severe hypothermia that rapidly deteriorated to cardiac arrest that was attributed to myxedema coma. Case Presentation: A 52-year-old man without a history of hypothyroidism was transferred to our emergency department due to coma and profound hypothermia. The patient developed cardiac arrest immediately after hospital arrival but return of spontaneous circulation was achieved shortly after resuscitation. The patient was noted to have generalized, nonpitting edema, dry skin, severe respiratory acidosis, hyponatremia, and elevated creatinine kinase, which was indicative of hypothyroidism. Myxedema coma was confirmed by a thyroid profile. The patient was successfully treated with intravenous levothyroxine and glucocorticoid. Conclusion: Although myxedema coma is a rare cause of severe hypothermia, emergency physicians should be familiar with its clinical features and management.
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Background: Sudden loss of consciousness as a result of cardiac arrest can cause severe traumatic head injury. Collapse-related traumatic intracranial hemorrhage (CRTIH) following out-of-hospital cardiac arrest (OHCA) may be linked to poor neurological outcomes; however, there is a paucity of data on this entity. This study aimed to investigate the frequency, characteristics, and outcomes of CRTIH following OHCA. Methods: Adult patients treated post-OHCA at 5 intensive care units who had head computed tomography (CT) scans were included in the study. CRTIH following OHCA was defined as a traumatic intracranial injury from collapse due to sudden loss of consciousness associated with OHCA. Patients with and without CRTIH were compared. The primary outcome assessed was the frequency of CRTIH following OHCA. Additionally, the clinical features, management, and consequences of CRTIH were analyzed descriptively. Results: CRTIH following OHCA was observed in 8 of 345 enrolled patients (2.3%). CRTIH was more frequent after collapse outside the home, from a standing position, or due to cardiac arrest with a cardiac etiology. Intracranial hematoma expansion on follow up CT was seen in 2 patients; both received anticoagulant therapy, and one required surgical evacuation. Three patients (37.5%) with CRTIH had favorable neurological outcomes 28 days after collapse. Conclusions: Despite its rare occurrence, physicians should pay special attention to CRTIH following OHCA during the post-resuscitation care period. Larger prospective studies are warranted to provide a more explicit picture of this clinical condition.
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BACKGROUND: The efficacies of fresh frozen plasma and coagulation factor transfusion have been widely evaluated in trauma-induced coagulopathy management during the acute post-injury phase. However, the efficacy of red blood cell transfusion has not been adequately investigated in patients with severe trauma, and the optimal hemoglobin target level during the acute post-injury and resuscitation phases remains unclear. Therefore, this study aimed to examine whether a restrictive transfusion strategy was clinically non-inferior to a liberal transfusion strategy during the acute post-injury phase. METHODS: This cluster-randomized, crossover, non-inferiority multicenter trial was conducted at 22 tertiary emergency medical institutions in Japan and included adult patients with severe trauma at risk of major bleeding. The institutions were allocated a restrictive or liberal transfusion strategy (target hemoglobin levels: 7-9 or 10-12 g/dL, respectively). The strategies were applied to patients immediately after arrival at the emergency department. The primary outcome was 28-day survival after arrival at the emergency department. Secondary outcomes included transfusion volume, complication rates, and event-free days. The non-inferiority margin was set at 3%. RESULTS: The 28-day survival rates of patients in the restrictive (n = 216) and liberal (n = 195) strategy groups were 92.1% and 91.3%, respectively. The adjusted odds ratio for 28-day survival in the restrictive versus liberal strategy group was 1.02 (95% confidence interval: 0.49-2.13). Significant non-inferiority was not observed. Transfusion volumes and hemoglobin levels were lower in the restrictive strategy group than in the liberal strategy group. No between-group differences were noted in complication rates or event-free days. CONCLUSIONS: Although non-inferiority of the restrictive versus liberal transfusion strategy for 28-day survival was not statistically significant, the mortality and complication rates were similar between the groups. The restrictive transfusion strategy results in a lower transfusion volume. TRIAL REGISTRATION NUMBER: umin.ac.jp/ctr: UMIN000034405, registration date: 8 October 2018.
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The coronavirus disease 2019 (COVID-19) global pandemic has drastically changed how we live and work. Amid the prolonged pandemic, burnout of the frontline healthcare professionals has become a significant concern. We conducted a cross-sectional survey study to provide data about the relationship between the COVID-19 pandemic and the prevalence of burnout in healthcare professionals in Japan. Healthcare workers in a single Japanese national university hospital participated in the survey, including basic demographics, whether a participant engaged in care of COVID-19 patients in the past 2 weeks and the Maslach Burnout Inventory. Of those, 25.4% fully answered the survey; 33.3% were doctors and 63.6% were nurses, and 36.3% engaged in care of COVID-19 patients in the past 2 weeks. Compared to those belonging to General Medicine, those in Emergency Intensive Care Unit were at higher risk of burnout (odds ratio (OR), 6.7; 95% CI, 1.1-42.1; p = 0.031). Of those who engaged in care of COVID-19 patients, 50% reported burnout while 6.1% did not (OR 8.5, 95% CI; 1.3-54.1; p = 0.014). The burnout of healthcare workers is a significant concern amid the pandemic, which needs to be addressed for sustainable healthcare delivery.
Subject(s)
Burnout, Professional , COVID-19 , Burnout, Professional/epidemiology , Cross-Sectional Studies , Health Personnel , Humans , Japan/epidemiology , Pandemics , SARS-CoV-2 , Surveys and QuestionnairesABSTRACT
The coronavirus disease 2019 (COVID-19) pandemic has posed a significant challenge to the modern healthcare system and led to increased burnout among healthcare workers (HCWs). We previously reported that HCWs who engaged in COVID-19 patient care had a significantly higher prevalence of burnout (50.0%) than those who did not in November 2020 (period 1). We performed follow-up surveys in HCWs in a Japanese national university hospital, including basic demographics, whether a participant engaged in care of COVID-19 patients in the past 2 weeks, and the Maslach Burnout Inventory in February 2021 (period 2) and May 2021 (period 3). Periods 1 and 3 were amid the surges of COVID-19 cases, and period 2 was a post-surge period with a comparatively small number of COVID-19 patients requiring hospitalization. Response rates to the surveys were 33/130 (25.4%) in period 1, 36/130 (27.7%) in period 2, and 56/162 (34.6%) in period 3, respectively. While no consistent tendency in the prevalence of burnout based on variables was observed throughout the periods, the prevalence of burnout tends to be higher in periods 1 and 3 in those who engaged in COVID-19 patient care in the last 2 weeks (50.0%, 30.8%, 43.1% in period 1, 2, and 3, respectively). Given the prolonged pandemic causing stigmatization and hatred against HCWs leading to increased prevalence of burnout, high-level interventions and supports are warranted.
Subject(s)
Burnout, Professional , COVID-19 , Burnout, Professional/epidemiology , Burnout, Psychological , Cross-Sectional Studies , Follow-Up Studies , Health Personnel , Humans , Pandemics , SARS-CoV-2ABSTRACT
Acute carbon monoxide (CO) intoxication during pregnancy causes fetal death and teratogenic effects. Hyperbaric oxygen (HBO2) therapy has the potential to improve them. HBO2 therapy should be considered to treat CO intoxication during pregnancy.
ABSTRACT
The ginkgo tree is a well-known, highly adaptable urban plant. Ginkgo nuts are the product of the ginkgo tree. Interior ginkgo nuts are cooked and served in Asian countries; however, the potential toxicity of the gingko nuts is not commonly known. Herein, we report a 48-year-old male patient experiencing acute convulsions presumably due to overconsumption of gingko nuts. The patient was transferred to our department after several episodes of acute generalized tonicclonic seizures lasting approximately 30 seconds each and starting one hour before the visit. The patient also complained of vomiting, vertigo, diarrhea, and tremors in both upper limbs following the seizures. Elevated 4-O-methylpyridoxine (312 ng/mL), low blood pyridoxal phosphate (2.4 µg/L), and low vitamin B1 (20 ng/mL) levels were found in the blood analysis. No other remarkable abnormalities were detected. We diagnosed the patient with ginkgo nut intoxication, and he was orally administered 400 mg of pyridoxal phosphate. His symptoms resolved after treatment, and no seizures recurred thereafter. Our report may help raise awareness of the clinical presentation and management of this intoxication among emergency physicians.
ABSTRACT
Patients with poorly controlled insulin-dependent type 1 or type 2 diabetes rarely present with glycogenic hepatopathy, which is characterized by hepatomegaly and liver enzyme abnormalities. Glycogenic hepatopathy occurs as a consequence of excessive accumulation of glycogen in hepatocytes caused by insulin. We report a young male patient with type 1 diabetes mellitus who developed glycogenic hepatopathy following a suicide attempt by insulin overdose via subcutaneous injection. The patient's medication/nutrition compliance and adherence to insulin were poorly controlled due to comorbid schizophrenia. Our patient required a large amount of continuous glucose to maintain euglycemia for persistent intractable hypoglycemia induced by overdose of long-acting insulin. On admission day 4, the patient presented elevated transaminases, hepatomegaly, and lactic acidosis. Computed tomography revealed swollen liver parenchyma with a diffusely high absorption. The patient gradually recovered without any medical intervention except for adequate control of blood sugar and was moved to a psychiatric ward on day 8 for schizophrenia management. This report may help emergency physicians be aware of the common symptoms, clinical course, and pathophysiology of glycogenic hepatopathy. Doctors should include glycogenic hepatopathy in the differential diagnosis of abnormal liver enzymes and hepatomegaly for those with poorly controlled insulin-dependent diabetes mellitus or unstable blood sugar levels due to insulin overdose like our patient.