Injury to a cardiopulmonary resuscitation provider by sternal wire.

Background: Median sternotomy is a common surgical procedure during cardiac and pulmonary surgeries. There are many reports of patient injury associated with wire breakage. However, there are only a few reports of healthcare worker injuries by sternal wire. Case Presentation: A patient in his 70s, having a history of thoracic aorta replacement, collapsed suddenly and paramedics started mechanical chest compression. On hospital arrival, the emergency department nurse attempted to initiate manual chest compression but was injured by a sternal wire protrusion on the patient's chest. The emergency physician placed gauze on the sternal wire and continued manual chest compression, but the patient died. Conclusion: To prevent this injury, cardiopulmonary resuscitation (CPR) providers should consciously check the patient's chest. If they observe wire exposure, they should immediately place a gauze, pad or consider performing mechanical chest compression. Safety measures such as the installing rubber pads in the AED should be considered.

Diphenyl-tetrazol-propanamide Derivatives Act as Dual-Specific Antagonists of Platelet CLEC-2 and Glycoprotein VI.

BACKGROUND: Platelet C-type lectin-like receptor 2 (CLEC-2) induces platelet activation and aggregation after clustering by its ligand podoplanin (PDPN). PDPN, which is not normally expressed in cells in contact with blood flow, is induced in inflammatory immune cells and some malignant tumor cells, thereby increasing the risk of venous thromboembolism (VTE) and tumor metastasis. Therefore, small-molecule compounds that can interfere with the PDPN-CLEC-2 axis have the potential to become selective antiplatelet agents. METHODS AND RESULTS: Using molecular docking analysis of CLEC-2 and a PDPN-CLEC-2 binding-inhibition assay, we identified a group of diphenyl-tetrazol-propanamide derivatives as novel CLEC-2 inhibitors. A total of 12 hit compounds also inhibited PDPN-induced platelet aggregation in humans and mice. Unexpectedly, these compounds also fit the collagen-binding pocket of the glycoprotein VI molecule, thereby inhibiting collagen interaction. These compounds also inhibited collagen-induced platelet aggregation, and one compound ameliorated collagen-induced thrombocytopenia in mice. For clinical use, these compounds will require a degree of chemical modification to decrease albumin binding. CONCLUSION: Nonetheless, as dual activation of platelets by collagen and PDPN-positive cells is expected to occur after the rupture of atherosclerotic plaques, these dual antagonists could represent a promising pharmacophore, particularly for arterial thrombosis, in addition to VTE and metastasis.

Massive haemothorax and haemorrhagic shock due to cervical vascular injury caused by a seat belt.

A woman in her 50s was transported to our hospital after experiencing a road traffic crash that led to a massive haemothorax and haemorrhagic shock due to a cervical vascular injury caused by the seat belt. Contrast-enhanced CT of the chest showed extravascular leakage of the contrast medium from the vicinity of the right subclavicular area and fluid accumulation in the thoracic cavity. The patient was intubated, and a thoracic drainage catheter was placed. She underwent angiography and embolisation of the right costocervical trunk, right thyrocervical trunk and right suprascapular artery using a gelatine sponge and 25% N-butylcyanoacrylate-Lipiodol. She was extubated on the second day after stabilisation of the respiratory and circulatory status. In cases where the bleeding vessel is known and an emergency thoracotomy can serve as a backup, embolisation by interventional radiology should be considered the initial treatment approach.

Comparison of serum and whole blood concentrations in quetiapine overdose cases.

This study aimed to compare whole blood and serum concentrations of quetiapine in acute poisoning cases. Authentic whole blood and respective serum samples were routinely collected from patients diagnosed with blood poisoning at our University Hospital. Accordingly, whole blood and serum paired samples from nine patients (one male and eight female patients) were analyzed for quetiapine using liquid chromatography-mass spectrometry (LC-MS). Quetiapine concentrations in whole blood and serum samples ranged widely from 5.4 to 2780 ng/mL and 9.9 to 2500 ng/mL, respectively. The whole blood/serum concentration ratio was 0.5-1.1 and increased together with an increase in whole blood and serum quetiapine concentrations. The ratio was reversed at around 2500 ng/mL to > 1. Our findings suggest that whole blood concentrations are more useful than serum concentrations in diagnosing quetiapine poisonings.

Autopsy Case Report of Severe COVID-19 Pneumonia at a General Municipal Hospital.

We present the autopsy procedure and findings of severe coronavirus disease 2019 (COVID-19) pneumonia in an 85-year-old man. The patient required intubation immediately after admission for severe COVID-19 pneumonia. He had severe hypoxia that did not improve despite treatment with remdesivir, corticosteroids, and appropriate mechanical ventilation. On day 13, the patient developed sudden hypercapnia. His renal dysfunction subsequently worsened and became associated with hyperkalemia, and he passed away on day 15. An autopsy was performed to clarify the cause of the hypercapnic hypoxia. None of the medical personnel involved in the autopsy developed symptoms of COVID-19. Histologic examination showed various stages of diffuse alveolar damage throughout the lungs, with intra-alveolar hemorrhage in the upper zones. Microscopic examination of the kidneys revealed acute tubular necrosis. There was no significant systemic thrombosis. The autopsy findings were consistent with those typical of COVID-19.

Two Cases of Minor Blunt Splenic Injury Accompanied with Unexpected Fatal Delayed Splenic Rupture.

Contrast blush (CB) is an area with a density higher than the organ parenchyma in the arterial phase of contrast-enhanced computed tomography (CT). CB may be a sign of contrast medium extravasation, pseudoaneurysm, arteriovenous fistula, or other conditions; however, the indications for treatment remain unclear. Nevertheless, CB could be used to indicate a fatal scenario, such as delayed splenic rupture. Here, we present two multiple-injury cases of fatal delayed splenic rupture following the nonoperative management of a minor splenic injury. In both cases, despite morphological CT findings being minor on admission, CB was observed, and both patients could not rest owing to factors such as older age, a head injury, and drunkenness. Furthermore, in the CB case that indicated pseudoaneurysm, delayed splenic rupture occurred much earlier after the injury compared to the other case without the possibility of pseudoaneurysm. In conclusion, we recommend transcatheter arterial embolization be urgently performed in a case wherein the presence of a pseudoaneurysm is highly probable and factors such as multiple injuries and inability to rest are involved.

Severe Sacral Region Pressure Ulcer Infection Treated in Negative Pressure Wound Therapy with Instillation and Dwelling: A Case Report.

We report a case of severe sacral osteomyelitis and sepsis with pressure ulcer infection treated with negative pressure wound therapy with instillation and dwelling (NPWTi-d) V.A.C.ULTA® from an early stage. Case: A 76-year-old man, bedridden because of dementia and an old cerebral infarction, was treated in a nursing facility for a sacral region pressure ulcer. He had a fever for three days and was transferred to the emergency department. The quick SOFA (sequential organ failure assessment) score at the hospital visit was three points. A coccyx and black mud-formed necrotic tissue attached to the sacral region pressure ulcer with a strong putrid odor sloughed off. Sacral region pressure ulcer infection, sepsis, disseminated intravascular coagulation, and purulent sacral osteomyelitis were diagnosed, and urgent debridement was performed. We treated the patient with meropenem, clindamycin, and vancomycin, and we performed irrigation debridement every day and transduced the V.A.C.ULTA® care system from AOD9, that led to good granulation at the infection site. The wound area underwent simple closure on AOD35 and the patient was transferred to the medical treatment hospital. Since dressing change is relatively easy in the emergency department of a secondary medical care institution with little man power, V.A.C.ULTA® therapy may be useful in treating severe cases of pressure ulcer infections.

Analysis of Grade Classification for Prehospital Injury Severity Scores Applied in Shonan-area Medical Control Council.

OBJECTIVE: To clarify the usefulness of grade classification for injury severity scores applied in Shonan-area Medical Control Council. METHODS: The participants included 11,668 injury cases that occurred in this jurisdiction from April to September 2016. Multivariate analysis was performed using "severity at the time of the disease" a s the response variable. The AUC-ROC was also compared with and without Grade classification, and potential improvements in discrimination ability were examined. RESULTS: There were 11,271 subjects in the "mild/moderate" group and 397 subjects in the "severe/dead" group. Almost all explanatory variables were significant and independent risk factors in the multivariate analysis, and the "Load & Go adaptation" had a particularly high odds ratio of 20.2. Discrimination ability improved (AUC-ROC: 0.773 VS. 0.787) when Grade classification was added to the conventional pre-hospitalization evaluation items. CONCLUSION: Load & Go adaptation has a great influence on severity, and discrimination ability is improved through Grade classification.

Should beta-blockers be continued as a treatment for myocardial infarction in the case of Kounis syndrome?

A 71-year-old male patient reported to our hospital with anaphylactic shock, and the following two issues were focused in this case. First, he was resistant to adrenaline because of taking beta-blocker, and shock was repeated until glucagon administration was initiated. Second, he developed acute coronary syndrome. Two mechanisms contributing to Kounis syndrome were differentiated: 1) adrenaline induced coronary spasm and platelet activation or 2) a mismatch between oxygen supply and demand due to an allergic reaction. Beta-blocker therapy was discontinued because his cardiac function was preserved. Secondary preventive beta-blockers in recovering myocardial infarction with severe anaphylaxis history should be carefully considered.

Serum potassium level as a biomarker for acute caffeine poisoning.

AIM: Acute caffeine poisoning presents with hypokalemia, although a relationship between potassium levels and blood concentrations of caffeine has not been established. A correlation between serum potassium level and blood caffeine concentration could establish serum potassium as a simple marker to assess caffeine toxicity in patients with acute toxicity. We investigated whether serum potassium, a symptom of acute caffeine poisoning, could be a parameter correlated with blood caffeine levels. METHODS: We enrolled 85 patients treated for acute caffeine poisoning between January 2012 and March 2019 with blood caffeine levels measured after an overdose of a caffeine-containing over-the-counter drug and for whom serum potassium levels were available. We examined the correlation between serum potassium and blood caffeine concentration. A receiver operating characteristic curve was created with serum potassium values to stratify participants into two groups by blood caffeine concentrations: <20 or ≥20 mg/L (toxic dose) and <80 or ≥80 mg/L (lethal dose). The lethal cut-off value was calculated. RESULTS: The correlation coefficient between serum potassium level and blood caffeine concentration was -0.612 (R 2 = 0.374), indicating a negative correlation. The areas under the curve at blood caffeine concentrations of 20 mg/L (toxic dose) and 80 mg/L (lethal dose) and serum potassium levels were 0.716 and 0.888 (sensitivity, 0.829 and 0.919; specificity, 0.568 and 0.818; cut-off, 3.3 mEq/L and 2.9 mEq/L), respectively. CONCLUSION: Serum potassium levels are associated with blood caffeine concentrations; K+ of 3.3 mEq/L and 2.9 mEq/L indicate acute caffeine poisoning in the toxic and lethal dose, respectively.

Optimal Treatment for Diverticulum-like Projections of the Retrohepatic Inferior Vena Cava Occurring after Inferior Vena Cava Packing: A Case Report.

INTRODUCTION: Although the outcomes of patients with retrohepatic inferior vena cava (IVC) injury have improved because of damage control (DC) strategies, some rare complications have been observed. CASE PRESENTATION: We present the case of a 35-year-old man with diverticulum-like projections (DLPs) of the retrohepatic IVC that occurred following peri-IVC packing based on DC strategies. The DLPs were treated conservatively with anticoagulant therapy and he recovered completely. CONCLUSIONS: Caution must be exercised regarding such rare complications after abbreviated surgery. Conservative therapy may be the optimal treatment for patients with DLPs of the retrohepatic IVC after peri-IVC packing.

Urinary glucose and ketone bodies as indicators of acute caffeine poisoning.

AIM: In various countries, many fatal health problems have been reported due to high intake of caffeine-rich energy drinks, tablets, and powders. In patients with acute caffeine poisoning, determination of blood caffeine concentration is an important yet difficult task. We aimed to assess whether the presence of glucose and ketone bodies in urine reflected the blood caffeine concentration in patients with acute caffeine poisoning. METHODS: From April 2010 to March 2018, 25 patients with an overdose of only caffeine-rich tablets were admitted to our hospital. Their clinical features were investigated. In addition, we investigated whether the glucose and ketone bodies in the urine reflected blood caffeine concentration in 23 patients who underwent the urine qualitative test at admission. RESULTS: The majority of the patients were young healthy women, whose average caffeine ingestion was 15.6 ± 8.1 g. Initial urine examinations showed glucose in 60% (14/23) of patients and ketone bodies in 57% (13/23) of patients. Ketone bodies or glucose were found in 78% (18/23) of the patients. The correlation between blood caffeine concentration and urinary glucose was R = 0.625, blood caffeine concentration and ketone bodies was R = 0.596, and blood caffeine and both was R = 0.76. CONCLUSION: Urine qualitative test is effective for differential diagnosis and severity assessment of acute caffeine poisoning in patients.

A Case of Acute Respiratory Distress Syndrome Caused by Waterproofing Spray Inhalation.

We report the case of a 62-year-old man who used approximately one can of waterproofing spray in an enclosed room and, then, smoked a cigarette. He developed a fever of 39°C with respiratory distress and was transported by ambulance to his usual doctor. Since his respiratory state was very severe, he was transferred to our hospital. The patient had a smoking habit of 20 cigarettes per day for approximately 42 years. Chest computed tomography (CT) on arrival showed ground glass opacity (GGO) in the bilateral lungs with emphysematous change. We diagnosed the patient with acute respiratory distress syndrome (ARDS) because of severe hypoxemia. Based on the symptoms' progress, the cause of ARDS was thought to be lung injury due to waterproofing spray inhalation, and treatment was accordingly initiated. Several reports have described lung injury caused by waterproofing spray inhalation; however, severe cases that progress to ARDS are rare. We believe that the aggravation was caused by smoking after inhaling the waterproofing spray and pre-existing pulmonary lesions, such as emphysema. Education regarding the precautions to be taken when using waterproofing spray is necessary.

Characteristic of the acute drug intoxication conveyed by Kanagawa helicopter emergency medical service.

Aim: Various critical cases have been transported since the use of the Kanagawa Helicopter Emergency Medical Service (HEMS) started at Tokai University Hospital (Isehara, Japan) in 2002, including cases of acute poisoning. We analyzed the characteristics of acute poisoning cases conveyed by the HEMS. Methods: Kanagawa HEMS conveyed 3,814 cases from July 2002 to March 2013, and acute drug and poison intoxication was diagnosed in 131 of these cases. We undertook a descriptive statistical study of these cases. Results: The causative agent was found to be psychiatric prescription drugs in 39.7% of cases, pesticides in 29.7%, alcohol in 8.4%, analgesics in 5.3%, detergent or bleach in 6.1%, oil, natural gas, or thinner in 4.6%, and others in 6.1%. At HEMS contact, systolic blood pressure was less than 90 mmHg in 18.3% of cases, and 40.2% were in coma. Endotracheal intubation was carried out in 44.5% of cases, and 6.9% died within 24 h of hospital admission. The cases of poisoning that we transported in the HEMS were often in shock and/or coma on arrival at the field, and rapid endotracheal intubation was required in nearly half of them, as many were in a serious condition. Conclusion: We believe that outcomes were more likely to be improved by appropriate early treatment by the HEMS. It will be necessary to further compare the ambulance service with the HEMS to evaluate their efficacy in the future.

Successful Treatment of Blunt Musculophrenic Artery Injury by Transcatheter Arterial Embolization: A Case Report.

An 86-year-old woman was transported by ambulance after jumping from the second floor of a building. Upon arrival, the blood pressure was stable; however, computed tomography indicated the presence of an anterior mediastinal hematoma. Eight hours after arrival, the patient exhibited shock. The blood pressure increased with rapid infusion. Emergency angiography was performed. Extravasation from the musculophrenic artery, which branches off from the left internal mammary artery, was observed. Transcatheter arterial embolization was performed and bleeding was controlled. This is the first report of musculophrenic artery injury caused by blunt trauma to the best of our knowledge. Findings suggested that if an anterior mediastinal hematoma develops, bleeding must be rapidly controlled. If the patient responds to rapid infusion and injury of the internal mammary artery or one of its branches is suspected, transcatheter arterial embolization is considered appropriate.

Two new species of Anatrichis LeConte (Coleoptera: Carabidae: Oodini) from Japan, with notes on the taxonomic position of Oodes infimus Andrewes.

Two new species of the genus Anatrichis LeConte, 1853 are described from Japan, A. morii, sp. n. (type locality: Fukuoka Prefecture, Shimotoubaru) and A. ryukyuensis, sp. n. (type locality: Okinawa Prefecture, Iriomote Island). Relevant diagnostic features of the new species are described, illustrated and compared with those of other species. A new combination is proposed: Anatrichis infima (Andrewes, 1936), comb. n. from Oodes infimus, and a lectotype designation is made for this species. The "indica" group of species is defined to include all the Asiatic congeners.

A Case of Blunt Traumatic Cardiac Tamponade Successfully Treated by Out-of-hospital Pericardial Drainage in a "Doctor-helicopter" Ambulance Staffed by Skilled Emergency Physicians.

We report a 55-year-old man who relapsed into a state of shock in an ambulance before arriving at our critical care center after a fall injury. The diagnosis of cardiac tamponade was made by portable ultrasound, and immediate pericardiocentesis and drainage were performed at the heliport. He was then transported immediately to our hospital with continuous drainage and surgery was performed. After surgery, the patient was transferred to the intensive care unit in stable condition. After undergoing rehabilitation, he made a full recovery and was discharged. This case illustrates that such patients can be treated reliably by pericardial drainage performed by skilled emergency physicians in the field by making use of the "doctor-helicopter" ambulance transportation system, followed by emergency surgery in a critical care center.

Comparative Effectiveness of Emergency Resuscitative Thoracotomy versus Closed Chest Compressions among Patients with Critical Blunt Trauma: A Nationwide Cohort Study in Japan.

BACKGROUND: Although emergency resuscitative thoracotomy is performed as a salvage maneuver for critical blunt trauma patients, evidence supporting superior effectiveness of emergency resuscitative thoracotomy compared to conventional closed-chest compressions remains insufficient. The objective of this study was to investigate whether emergency resuscitative thoracotomy at the emergency department or in the operating room was associated with favourable outcomes after blunt trauma and to compare its effectiveness with that of closed-chest compressions. METHODS: This was a retrospective nationwide cohort study. Data were obtained from the Japan Trauma Data Bank for the period between 2004 and 2012. The primary and secondary outcomes were patient survival rates 24 h and 28 d after emergency department arrival. Statistical analyses were performed using multivariable generalized mixed-effects regression analysis. We adjusted for the effects of different hospitals by introducing random intercepts in regression analysis to account for the differential quality of emergency resuscitative thoracotomy at hospitals where patients in cardiac arrest were treated. Sensitivity analyses were performed using propensity score matching. RESULTS: In total, 1,377 consecutive, critical blunt trauma patients who received cardiopulmonary resuscitation in the emergency department or operating room were included in the study. Of these patients, 484 (35.1%) underwent emergency resuscitative thoracotomy and 893 (64.9%) received closed-chest compressions. Compared to closed-chest compressions, emergency resuscitative thoracotomy was associated with lower survival rate 24 h after emergency department arrival (4.5% vs. 17.5%, respectively, P < 0.001) and 28 d after arrival (1.2% vs. 6.0%, respectively, P < 0.001). Multivariable generalized mixed-effects regression analysis with and without a propensity score-matched dataset revealed that the odds ratio for an unfavorable survival rate after 24 h was lower for emergency resuscitative thoracotomy than for closed-chest compressions (P < 0.001). CONCLUSIONS: Emergency resuscitative thoracotomy was independently associated with decreased odds of a favorable survival rate compared to closed-chest compressions.