Advanced do-not-attempt-resuscitation directives and emergency medical services for out-of-hospital cardiopulmonary arrest patients in Japan: a pilot study.

AIMS: We investigated how do-not-attempt-resuscitation (DNAR) orders are currently used, and we examined the emergency medical team responses for out-of-hospital cardiac arrest (OHCA) cases in Japan. METHODS: The sample for this prospective study comprised all OHCA cases attended to by the Sagamihara Municipal Fire Department emergency medical services between May 30, 2019 and February 15, 2020. Data were recorded by the responding emergency medical team. RESULTS: There were 396 OHCA cases. The mean age was 75 ± 18 years, and individuals aged 65 years or older accounted for 80.6%. Approximately 70% of the patients had an underlying disease. A DNAR order was available in only 45 (11.4%) of the cases, of which 12 (26.7%) were written, 27 (60%) were verbally confirmed, and six (13.3%) were confirmed in some other way or both. The home physician was present and able to confirm the patient's death in only one of the DNAR cases. In 43 (95.6%) of the cases, the emergency medical team carried out cardiopulmonary resuscitation despite a DNAR order; of them, a total of 17 (37.8%) patients were transported to a tertiary emergency hospital. CONCLUSIONS: Our analyses indicate the under-utilization of DNAR advance directives and advance care planning (which are important for better end-of-life care) in Japan. Currently, an emergency medical team could be required to attempt resuscitation against an individuals' clear DNAR order. In the future, legal arrangements regarding the handling of DNAR directives on site may be required to respect patients' wishes.

Life-threatening traumatic epistaxis due to massive bleeding into the maxillary sinus.

A 77-year-old woman with no medical history fell, and her face was strongly impacted on the ground. On arrival at our hospital, her initial vital signs were stable. She underwent an endoscopy to stop the bleeding. However, identification of the origin of the bleeding failed, and her injury resulted in hemorrhagic shock during the procedure. Head to face contrast computed tomography showed extravasation of contrast media into the maxillary sinus. Transcatheter arterial embolization was performed for the ruptured infraorbital artery branching from the maxillary artery. She recovered from the "shock" state after transcatheter arterial embolization and was admitted to the intensive care unit. There were no complications associated with transcatheter arterial embolization during hospitalization. For this case, early recognition of an active hemorrhage was challenging because the hemorrhage was pooled in the sinuses. Although epistaxis is sometimes fatal, transcatheter arterial embolization can be the first choice for the treatment of life-threatening epistaxis, owing to its safety and effectiveness.

Novel transcatheter arterial embolization method for hemodynamically unstable pelvic fractures to prevent complications of gluteal necrosis.

PURPOSE: To validate our previously designed transcatheter arterial embolization (TAE) technique for bilateral iliac arteries in unstable pelvic fractures, which is designed to also prevent gluteal necrosis and avoid vasopressors. METHODS: We retrospectively analyzed the data of patients with pelvic fractures who underwent our new TAE procedure to determine the incidence of subsequent gluteal necrosis. We also compared certain variables between patients who underwent TAE before 2005 using a different technique and developed gluteal necrosis and patients who underwent TAE in 2005 and onward using our technique. Gluteal necrosis was confirmed by a radiologist based on imaging findings. RESULTS: Seventy patients with pelvic fractures who underwent our TAE technique met the inclusion criteria (bilateral iliac arterial embolization and no embolic agent other than a gelatin sponge). Patients' median age was 47.5 years, 33 were male, and 92.9% (65/70) had unstable fractures. Sixty-eight patients had severe multiple trauma. No patients developed gluteal necrosis following our TAE procedure and the overall survival rate was 82.9% (58/70). We found no statistically significant difference in procedure time between the previous and new technique, although the new procedure tended to be shorter. Furthermore, overall survival did not significantly differ between the groups. Multiple regression analysis revealed that TAE procedure time and external pelvic fracture fixation were independently related to gluteal necrosis. CONCLUSIONS: Our non-selective bilateral iliac arterial embolization procedure involves arresting shock quickly, resulting in no post-procedure gluteal necrosis. The procedure involves cutting the gelatin sponge rather than "pumping" and avoids the use of vasopressors.