Detection of acute rib fractures on CT images with convolutional neural networks: effect of location and type of fracture and reader's experience.

PURPOSE: The evaluation of all ribs on thin-slice CT images is time consuming and it can be difficult to accurately assess the location and type of rib fracture in an emergency. The aim of our study was to develop and validate a convolutional neural network (CNN) algorithm for the detection of acute rib fractures on thoracic CT images and to investigate the effect of the CNN algorithm on radiologists' performance. METHODS: The dataset for development of a CNN consisted of 539 thoracic CT scans with 4906 acute rib fractures. A three-dimensional faster region-based CNN was trained and evaluated by using tenfold cross-validation. For an observer performance study to investigate the effect of CNN outputs on radiologists' performance, 30 thoracic CT scans (28 scans with 90 acute rib fractures and 2 without rib fractures) which were not included in the development dataset were used. Observer performance study involved eight radiologists who evaluated CT images first without and second with CNN outputs. The diagnostic performance was assessed by using figure of merit (FOM) values obtained from the jackknife free-response receiver operating characteristic (JAFROC) analysis. RESULTS: When radiologists used the CNN output for detection of rib fractures, the mean FOM value significantly increased for all readers (0.759 to 0.819, P = 0.0004) and for displaced (0.925 to 0.995, P = 0.0028) and non-displaced fractures (0.678 to 0.732, P = 0.0116). At all rib levels except for the 1st and 12th ribs, the radiologists' true-positive fraction of the detection became significantly increased by using the CNN outputs. CONCLUSION: The CNN specialized for the detection of acute rib fractures on CT images can improve the radiologists' diagnostic performance regardless of the type of fractures and reader's experience. Further studies are needed to clarify the usefulness of the CNN for the detection of acute rib fractures on CT images in actual clinical practice.

The impact of helicopter emergency medical services and craniocervical traction on the early reduction of cervical spine dislocation in a rural area of Japan.

BACKGROUND: Several studies have shown an association between achieving decompression of the spinal cord within a few hours and neurological recovery, even in patients with complete paralysis due to cervical spine dislocation. This study aimed to clarify the impact of helicopter emergency medical services (HEMSs) and craniocervical traction on the rapid reduction of lower cervical spine dislocation in rural Japan. METHODS: The success rate of and factors inhibiting closed reduction, the time from injury to reduction and the functional prognosis of lower cervical spine dislocations treated between July 2012 and February 2020 were retrospectively analysed. RESULTS: Fourteen patients were transported by HEMS (group H), seven by ambulance (group A) and two by themselves. Although the average traveled distance and injury severity score were significantly higher in group H (64.5 km, 28.0) than in group A (24.7 km, 18.6), there was no significant difference in the average time to admission or the time to initiation of craniocervical traction after admission between groups H (159.4 min, 52.2 min) and A (163.6 min, 53.2 min). The success rate of closed reduction was 95%, and neurological deterioration was not observed in any cases. The average traction time and weight for reduction were 30.3 min and 16.3 kg, respectively. Body size and fracture-dislocation type did not significantly affect the traction time or weight. The rate of reduction within 4 h after injury was higher in group H (79%) than in group A (33%). Inner fixations were treated an average of 5.7 days after admission. After treatment, three of nine AIS A patients recovered the ability to walk, and all three patients underwent successful closed reduction within 4 h after injury. CONCLUSION: HEMS and highly successful closed reduction contributed to the early reduction of cervical spine dislocation and can potentially improve complete paralysis.

Current status of trauma surgery at a Japanese prefectural academic institute: improved organization in a regional prefecture.

PURPOSES: Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital. METHODS: This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012. RESULTS: Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death. CONCLUSION: Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Conditional unnecessity of head CT for whole-body CT of traffic accident victims: a pilot study.

PURPOSE: To investigate whether head CT should be included in whole-body CT in road traffic accident victims. METHODS: A review of electronic medical records identified 124 patients (81 males, 43 females; age 4 to 92 years, mean 47.7 years) involved in a road traffic accident in a 12-month period. All had undergone whole-body CT and physical and neurologic examinations. We recorded their age, sex, Glasgow Coma Scale (GCS), systolic blood pressure (SBP), the type of traffic accident, and the presence/absence of visible trauma above the clavicles (VTCs) and of acute traumatic brain injury (TBI) on CT. Statistical analyses were performed to evaluate predictors of acute TBI. RESULTS: Of 124 patients, 34 (27%) manifested acute TBI on CT. Univariate analysis identified their age, GCS, SBP, VTCs, and the accident type as statistically significant factors for acute TBI (p < 0.05). Multivariate analysis demonstrated VTCs, GCS score < 15, and SBP ≤ 90 mmHg were significant independent predictors of acute TBI (p = 0.001, p = 0.001, and p = 0.004, respectively); the odds ratio was 16.07 for VTCs, 14.85 for GCS score < 15, and 13.78 for SBP ≤ 90 mmHg. No patients without both decrease in GCS score and VTCs manifested acute TBI. CONCLUSION: Our pilot study showed that visible trauma above the clavicles and decrease in GCS score were highly associated with the presence of acute TBI in road traffic accident victims. In whole-body CT, a head CT may not be indicated in patients without these factors.

Weather Webcam System for the Safety of Helicopter Emergency Medical Services in Miyazaki, Japan.

OBJECTIVE: In Japan, the helicopter emergency medical services (HEMS) system was initiated in 2001 and introduced to Miyazaki Prefecture in 2012. Mountainous areas occupy 88% of Miyazaki's land area, and HEMS flights can be subject to the effects of weather. Therefore, ensuring safety in changing weather conditions is a necessity for HEMS. METHODS: The weather webcam system (WWS) was established to observe the meteorological conditions in 29 locations. Assessments of the probability of a flight based on conventional data including a weather chart provided by the Japan Meteorological Agency and meteorological reports provided by the Miyazaki Airport were compared with the assessment based on the combination of the information obtained from the WWS and the conventional data. RESULTS: The results showed that the probability of a flight by HEMS increased when using the WSS, leading to an increased transportation opportunity for patients in the mountains who rely on HEMS. In addition, the results indicate that the WWS may prevent flights in unfavorable weather conditions. CONCLUSION: The WWS used in conjunction with conventional weather data within Miyazaki HEMS increased the pilot's awareness of current weather conditions throughout the Prefecture, increasing the probability of accepting a flight.

Changes in coagulation factor XIII activity during resuscitation for hemorrhagic shock.

Objective: Little is known about the coagulation activity of factor XIII (FXIII) during resuscitation for hemorrhagic shock and the effects of plasma transfusions. We performed a single-center observational study to evaluate the changes in FXIII activity during resuscitation for hemorrhagic shock. Patient and Methods: Twenty-three adult patients with hemorrhagic shock were enrolled in this study. Blood samples were drawn upon arrival (T1), at the time of hemostasis completion (T2), and on day 2 (T3). Baseline and changes in FXIII activity and the proportion of patients with adequate levels of FXIII activity (FXIII activity >70%) were evaluated. The effects of plasma transfusion on these parameters were also investigated. Results: At T1, the median (interquartile range) FXIII activity was 53% (47-85%), which did not increase (T1 vs. T3: 53% [47-85%] vs. 63% [52-70%], P=0.8766). The proportion of patients with adequate FXIII activity decreased throughout the resuscitation period (T1, T2, and T3: 30, 34, and 21%, respectively). Plasma transfusion did not affect FXIII activity (T1 vs. T2, 66.4% [23.4] vs. 70.0% [16.2%], P=0.3956; T2 vs. T3, 72.0% [19.5] vs. 63.5% [8.6%], P=0.1161) or the proportion of adequate levels of FXIII activity at 44% at T2 and 27% at T3. Conclusion: FXIII activity is low during the early phase of a hemorrhagic shock. Even with plasma transfusion, FXIII levels were not adequately maintained throughout resuscitation.

Should an emergency physician be a "surgeon" in a rural area? A case of blunt cardiac rupture successfully treated by an emergency physician.

Objective: Blunt cardiac rupture is a life-threatening injury that requires surgical repair by cardiovascular or trauma surgeons. We report a case of blunt cardiac rupture in a rural area in which emergency physicians performed emergency department thoracotomy and surgical repair to save the patient's life. Patient and Methods: This case involved an 18-year-old female who was injured in a traffic accident and underwent emergency thoracotomy and surgical repair. Results: The patient's left thorax was deformed, and sonographic assessment revealed pericardial effusion. She experienced cardiopulmonary arrest 13 min after hospital arrival. An emergency physician performed an emergency department thoracotomy. The clots were removed from the surface of the left ventricle, followed by wound compression to control bleeding from the ruptured left ventricular wall. After the recovery of spontaneous circulation, the emergency physician sutured the ruptured heart. The patient survived with good neurological function. Conclusion: In rural areas, blunt cardiac rupture may require emergency department thoracotomy and cardiac repair by emergency physicians. The establishment of educational systems that include continuous education on trauma surgical procedures and consensus guidelines is needed to assist rural emergency physicians in performing surgical procedures.

Cardiac Tamponade Due to Intrapericardial Hernia Mimicking ST-Segment Elevation Myocardial Infarction.

Intrapericardial hernia is a diaphragmatic hernia that extremely rarely causes cardiac tamponade. We present a case of a cardiac tamponade caused by an intrapericardial hernia in a 78-year-old male patient with a history of coronary artery bypass grafting, mimicking ST-segment elevation myocardial infarction, which was successfully treated by emergent laparotomy.

Venous Thoracic Outlet Syndrome with an Upper Extremity Deep Vein Thrombosis Caused by a Dislocated Clavicle Fracture: A Case Report.

BACKGROUND Clavicle fractures are a relatively common injury, and are not problematic when occurring alone. Venous thoracic outlet syndrome (TOS) is generally caused by compression of the subclavian vein between the first rib and oblique muscles, and is often complicated by the presence of upper extremities deep vein thrombosis (UEDVT). Herein, we present a case of venous TOS complicated with UEDVT due to a dislocated clavicle fracture. CASE REPORT A 29-year-old man was injured in a motorcycle accident. The patient's right clavicle was fractured, and the distal part of the fracture had dislocated into his right thorax. Contrast-enhanced computed tomography showed an obstruction of the subclavian vein by the dislocated clavicle and thrombus on the distal side of the obstruction. Anticoagulant therapy was not indicated because of other injuries, such as traumatic subarachnoid hemorrhage. No vena cava filter was placed in the superior vena cava owing to the relatively low volume of the thrombus. Alternatively, intermittent pneumatic compression to the right forearm was initiated. On day 6, surgical reduction of the clavicle was performed. The thrombus remained after the reduction. The patient received anticoagulation therapy with heparin followed by oral anticoagulants. The patient was discharged without any complications of UEDVT or bleeding. CONCLUSIONS Venous TOS with UEDVT caused by trauma is rare. Anticoagulation therapy, pneumatic limb compression, and vena cava filter placement should be considered according to the degree of the obstruction and other associated injuries.

A pediatric case of multiple trauma with impending cardiac arrest due to hemorrhagic shock successfully treated with resuscitative thoracotomy: A case report.

Background: The effectiveness of resuscitative thoracotomy (RT) in pediatric patients with multiple trauma is limited. We present a pediatric case of multiple trauma successfully treated with RT. Case Presentation: A 9-year-old boy was injured after falling down stairs. On arrival, his blood pressure was unmeasurable, and the carotid artery pulse was barely palpable. Sonographic assessment indicated intra-abdominal hemorrhage. RT and aortic cross-clamping were performed, and he received a blood transfusion, after which his circulatory status recovered. Laparotomy indicated an inferior mesenteric vein injury that was sutured. Ten hours after arrival, an acute epidural hematoma was observed and treated with an emergency craniotomy. The patient's condition remained stable and he was discharged on the 101st day. Conclusion: RT may save the life of patients with multiple trauma, even pediatric patients, if performed in a timely manner, based on the diagnosis of hemorrhagic shock, along with rapid transfusion and hemostatic intervention.

Successful Treatment of Sepsis-Induced Cardiomyopathy with Intra-Aortic Balloon Pumping: A Case Report and Literature Review.

BACKGROUND Sepsis-induced cardiomyopathy is cardiac dysfunction in sepsis that sometimes results in reduced cardiac output. Inotropic agents are recommended in patients with sepsis and cardiac dysfunction. Here, we present a case of sepsis-induced cardiomyopathy that was resistant to inotropes and was successfully treated with intra-aortic balloon pumping (IABP). We also reviewed the literature on similar cases of sepsis-induced cardiomyopathy treated with IABP. CASE REPORT A 40-year-old woman with fever and hypotension was admitted to a university hospital. Laboratory test results showed elevated inflammatory markers and cardiac markers, such as creatinine kinase-MB and troponin T. Echocardiography revealed severe left ventricular hypokinesis, and cardiac monitoring revealed a low cardiac output. The patient received antimicrobials, vasopressors, and dobutamine; however, her circulatory status did not respond to these treatments. IABP was introduced 7 h after admission and dramatically increased her blood pressure and cardiac output, resulting in the reduction of vasopressor and dobutamine doses. The patient survived without any IABP-related complications. The literature review of 11 cases of sepsis-induced cardiomyopathy treated with IABP shows consistent results with the presented case in terms of positive effects of IABP on circulatory status and cardiac function, resulting in a reduction of inotropes. CONCLUSIONS Some sepsis-induced cardiomyopathy cases with reduced left ventricular function may not respond to inotropes. IABP would be a treatment option for these patients because of its positive effects on cardiac and circulatory functions.

The clinical impact of the ratio of C-reactive protein to albumin (CAR) in patients with acute- and lymphoma-type adult T-cell leukemia-lymphoma (ATL).

Recently, the ratio of C-reactive protein to albumin (CAR) is used as an inflammatory marker that has been demonstrated to be a simple and reliable prognostic factor in solid tumors and hematological malignancy. However, no studies of the CAR have been performed in patients with adult T-cell leukemia-lymphoma (ATL). We retrospectively analyzed the clinical features and outcomes in 68 newly diagnosed acute- and lymphoma-type ATL [(acute-(n=42) or lymphoma-type (n=26)] patients in Miyazaki Prefecture from 2013 to 2017. Furthermore, we investigated correlations between pretreatment CAR levels and clinical features. The median age was 67 years (range, 44 - 87). Patients were initially treated by either palliative therapy (n=14) or chemotherapy [n=54; CHOP therapy (n=37)/ VCAP-AMP-VECP therapy (n=17)], and showed median survival durations of 0.5 months and 7.4 months, respectively. The factors affecting OS by multivariate analysis were age, BUN, and CAR. Importantly, we revealed that the high CAR group (optimal cut-off point; 0.553) was a significant indicator of worse OS by multivariate analysis (p< 0.001, HR; 5.46). The median survival of patients with a CAR< 0.553 was 8.37 months, while patients with a CAR>0.553 had a median survival of 3.94 months. The different clinical features between high CAR and low CAR groups were hypoproteinemia and the implementation of chemotherapy. Furthermore, in the chemotherapy group, but not the palliative therapy group, CAR was a significant prognostic marker. Our study indicated that CAR may be a new simple and significant independent prognostic marker in acute- and lymphoma-type ATL patients.

Clinical features and treatment outcomes of isolated secondary central nervous system lymphomas in Miyazaki Prefecture.

BACKGROUND: Secondary central nervous system lymphoma (SCNSL) without extra-central nervous system (CNS) involvement is characterized by isolated secondary CNS relapse in malignant lymphoma patients. SCNSL is a rare disease, and no standard treatment has yet been established. PATIENTS AND METHODS: To elucidate the clinical characteristics and outcomes of SCNSL, we retrospectively analyzed 12 patients (median age 67 years) in Miyazaki prefecture for the last 5 years. RESULTS: The initial histological diagnoses of the patients were diffuse large B-cell lymphoma (DLBCL), mantle-cell lymphoma, and adult T-cell lymphoma in 9, 2, and 1 patient, respectively. We focused on analysis of the 9 SCNSL cases originating from DLBCL. The locations of CNS relapse were the cerebral hemisphere, basal ganglia, and cerebellum in 7, 1, and 1 patient, respectively. Three patients were treated with high-dose methotrexate (HD-MTX) therapy; 4 with whole-brain radiation therapy (WBRTX); and 1 with both HD-MTX and WBRTX. The remaining patients were treated with rituximab. Partial remission was achieved in 6 out of 9 patients (67%); the other 3 patients (33%) did not respond to therapy. Median survival of the 9 patients with CNS relapse was 253 days; 6 of the 9 patients survived for more than 6 months. As of March 2011, 2 HD-MTX group patients but none of the WBRTX group patients were alive. CONCLUSIONS: In this retrospective study, 6 of 9 patients with SCNSL originating from DLBCL survived for more than 6 months. Both HD-MTX and WBRTX had clinical benefits in the treatment of SCNSL.

Cerebral phaeohyphomycosis: case report.

Cerebral phaeohyphomycosis is a rare and frequently fatal disease. This disease is often caused by hematogenous spread of pathogens that are inoculated in the skin of the extremities after slight or minor trauma, and its mortality rate is rather high despite aggressive treatment. Our patient presented with headache and pyrexia. She was diagnosed with fungal meningitis and treated by systemic administration of voriconazole (VRCZ). However, after initial improvement, meningitis recurred. MRI of the brain showed multiple small masses in the cerebral hemisphere and she was thus referred to our Department of Neurosurgery. On admission, an examination showed that the masses were deeply located in the brain and were too small to be excised; therefore, treatment with systemic VRCZ and intrathecal amphotericin B was initially selected. However, the intracerebral masses continued to grow; therefore, they were surgically excised. Histological examination of the surgical specimens at that time identified the masses as granuloma caused by infection with Aspergillus niger. After the surgery, her general condition improved; therefore treatment with systemic and intrathecal antifungal agents were continued. However, the intracerebral masses recurred, and despite further aggressive surgical treatment and systemic and intrathecal antifungal administration, she died 43 months after the initial diagnosis. Autopsy examination showed that the cerebral lesions were phaeohyphomycotic granulomas. This paper describes the clinical presentation, histopathological results and treatment for this rare disease.

Thrombotic Microangiopathy Secondary to Systemic Sclerosis with Severe Complement Activation Not Responsive to Eculizumab: A Case Report.

BACKGROUND Secondary thrombotic microangiopathies (TMAs) are induced by several underlying conditions and most are resolved by treating the underlying disease. Eculizumab, a human monoclonal antibody, blocks the final stages of the complement system. Several studies have shown that complement C5 monoclonal antibodies are effective in treating secondary TMA. Systemic sclerosis (SSc) is one of the most common causes of secondary TMA, and early diagnosis is important because TMA secondary to SSc has a poor prognosis. We report a case of TMA secondary to SSc that did not respond to eculizumab, despite the presence of severe complement activation. CASE REPORT A 61-year-old previously healthy man was admitted for acute renal failure and thrombocytopenia. TMA was suspected because hemolytic anemia, thrombocytopenia, and organ damage were detected. Based on the physical findings, we suspected SSc as the underlying cause. All tests for specific antibodies, including Scl-70, were negative, and C5b-9 levels were markedly elevated (11 041 ng/mL). We initiated plasma exchange on day 3, followed by eculizumab therapy, but with limited improvement. SSc with secondary TMA was identified upon further testing. After completion of the plasma exchange, the platelet count was maintained above 30 000/µL. Creatinine levels gradually decreased, and the patient was weaned off dialysis. Steroid treatment for SSc was continued, and the patient was eventually discharged. CONCLUSIONS A case of SSc-TMA was ineffectively treated with eculizumab, despite abnormal activation of the complement system. Continuous monitoring and investigation are required, and discontinuation of eculizumab should be determined according to the final diagnosis.

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study.

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS. Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy. Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0-8.5] h vs. 1.0 [0.5-2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0-5.0] days vs. 2.0 [1.0-2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0-33.0] days vs. 9.0 [5.0-15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy. Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Severe Traumatic Brain Injury in a Patient with von Willebrand Disease Type 2A Successfully Treated with Factor VIII/von Willebrand Factor Concentrates: A Case Report.

BACKGROUND von Willebrand disease (VWD) is characterized by a bleeding tendency due to abnormalities in von Willebrand factor (VWF). Severe traumatic brain injury (TBI) can induce secondary coagulopathy and hemostatic disorders. We herein present a rare case of multiple trauma, including severe TBI, in a patient with VWD who was successfully treated with repeated factor VIII/VWF transfusion in addition to standard critical care. CASE REPORT A 22-year-old man with type 2A VWD sustained head and lower limb injuries in a traffic accident and was comatose. Computed tomography indicated multiple trauma, including severe TBI (left-sided traumatic epidural hematoma, left-sided traumatic subdural hematoma, traumatic subarachnoid hemorrhage, skull fracture, and skull base fracture). The patient underwent emergency craniotomy for hematoma removal, external decompression, and intracranial pressure monitoring along with massive transfusion and repeated perioperative transfusion of factor VIII/VWF concentrates according to the level of bleeding. He recovered consciousness and eventually survived without neurological deficits. CONCLUSIONS Multiple trauma including TBI in patients with VWD is a critical condition. The active transfusion of factor VIII/VWF is essential for controlling hemorrhage early and in the perioperative period.

Physician-Staffed Emergency Vehicle Crash: A Case Report.

Physician-staffed vehicles are widely operated in many countries. There is a paucity of literature regarding physician-staffed emergency vehicle accidents. On an evening in January 2016, at the request of the fire department, a physician-staffed vehicle was dispatched with two physicians, a nurse, and a driver from the base hospital to the scene of a patient with cardiopulmonary arrest. The vehicle ran with the alerting siren and warning lights. On its way, the vehicle struck a car and the mission was canceled. The patient was transported to another hospital by the ambulance staff only. No passengers were injured. One physician and a nurse examined the driver of the struck car and transported the driver to the base hospital by additional ambulance units. Because there were no manuals or guidelines, the staff responses were not systematic. After the repair of the crashed vehicle and preparation of operation manuals for two months, the physician-staffed vehicle returned to service, and it has worked without any accident since then. The physician-staffed vehicle is of benefit to critical victims and it rarely crashes. When the vehicle is involved in an accident, it results in multiple victims as well as additional emergency demands. Warning lights and sirens in the dark at a four-point crossroads might increase the risk of crashing. Information influx from the emergency scenes might distract the physicians' attention and put stress on the driver, leading to dangerous high-speed emergency driving. Educational training and manuals in each hospital and a nationwide framework regarding safety operations and accidents are needed.

Knowledge survey regarding blast wound education of student doctors at a local academic medical university in Japan.

Objectives: To improve knowledge about blast injury for medical student doctors or surgeons. In the modern uncertain era, education and training programs for blast injuries for medical student doctors or surgeons are recently necessary worldwide. Material and Methods: To understand primary corresponding ability to treat blast injuries, leading to improvement of the trauma education curriculum, a retrospective study by a knowledge survey was performed between 2018 and 2019. The subject had the title of Student Doctor (SD) at university. Results: The answers of 183 participants who answered the interview questionnaire with 16 questions were summarized. Although most SDs received basic lectures for trauma medicine and majority of SDs knew about mass casualty incidents and primary treatment, the existence of knowledge on soft targets is limited. One-fourth of the SDs knew the characteristics of blast wounds. Most SDs understood priority triage for a conscious person with massive bleeding from a limb with hemostasis to save lives. The 17% selected cardiopulmonary resuscitation first and 72% of SDs could explain hemorrhagic shock; however, only four could explain adequate hemostatic procedures. Most had no interest regarding necessity of their knowledge in the field of serious blast trauma wounds. Conclusion: Experience in trauma surgery training from stages in SDs and authorized education are important for raising students' knowledge of unexpected serious blast incidents.