Novel and innovative resuscitation systems in Japan.

Aim: Out-of-hospital cardiac arrest (OHCA) is a life-threatening emergency that requires rapid and efficient intervention. Recently, several novel approaches have emerged and have been incorporated into resuscitation systems in some local areas of Japan. This review describes innovative resuscitation systems and highlights their strengths. Main text: First, we discuss the deployment of a physician-staffed ambulance, in which emergency physicians offer advanced resuscitation to patients with OHCA on site. In addition, we describe the experimental practice of extracorporeal membrane oxygenation (ECPR) in a prehospital setting. Second, we describe a physician-staffed helicopter, wherein a medical team provides advanced resuscitation at the scene. We also explain their initiative to provide early ECPR, even in remote areas. Finally, we provide an overview of the "hybrid ER" system which is a "one-fits-all" resuscitation bay equipped with computed tomography and fluoroscopy equipment. This system is expected to help swiftly identify and rule out irreversible causes of cardiac arrest, such as massive subarachnoid hemorrhage, and implement ECPR without delay. Conclusion: Although these revolutionary approaches may improve the outcomes of patients with OHCA, evidence of their effectiveness remains limited. In addition, it is crucial to ensure cost-effectiveness and sustainability. We will continue to work diligently to assess the effectiveness of these systems and focus on the development of cost-effective and sustainable systems.

Effectiveness of a doctor dispatch system activated by an advanced automatic collision notification from a single-vehicle accident: A case report.

A 79-year-old woman collided with a cliff in a passenger automobile. The fire department acknowledged an automated collision notification from the D-Call Net (DCN) at 1 min after the accident and called for doctors by helicopter ("Doctor-Heli" [DH] in Japan) 9 min after the injury. The DH reached the victim 28 min after the injury, and examinations revealed pain in the right side of her chest, tachypnea, and a weak radial artery pulse (indicating shock). The DH arrived at the hospital 49 min after the injury. A thoracic drainage was performed for right-sided tension pneumothorax. She recovered from the shock, but was diagnosed with flail chest and placed on a respirator. She was extubated on postoperative day 6 and transferred to a rehabilitation hospital on postoperative day 57. Due to the DCN, the patient received treatment 15 min earlier than the time taken by the conventional system. Emergency response task forces must develop strategies for connecting DCN warnings to a rapid medical response.

Do Video Calls Improve Dispatcher-Assisted First Aid for Infants with Foreign Body Airway Obstruction? A Randomized Controlled Trial/Simulation Study.

BACKGROUND: Because choking quickly leads to cardiopulmonary arrest, it is crucial that bystanders remove foreign bodies effectively. Although oral instructions in video calls by dispatchers have improved the quality of cardiopulmonary resuscitation, it is unclear whether video calls improve the quality of first aid for choking infants. Therefore, this simulation study aimed to determine whether video calls with dispatchers improve the quality of first aid for infants with foreign body airway obstruction (FBAO). METHODS: Seventy first-year college students randomly assigned in pairs to communicate by video or audio calls participated in simulated emergency calls for infants with FBAO. Both groups began with oral instruction in voice calls until the transition was made to video calls in the video group. The primary outcome was quality of first aid performance, which was categorized as excellent, acceptable, or poor on the basis of existing guidelines. RESULTS: There were 17 simulations in the video-call groups and 16 in the voice-call groups. After initial oral instruction, the proportion of rescuers that received an evaluation of excellent or acceptable did not differ significantly between the groups (video, 41% vs. voice, 50%; P=0.61); however, evaluations for seven rescuers improved after transitioning to video calls. Ultimately, the proportion receiving a poor evaluation was significantly lower in the video-call group than in the voice-call group (50% vs. 82%, P=0.049). CONCLUSION: Oral instruction communicated by video calls improved the quality of first aid for infants with FBAO.

Impact of Induced Therapeutic Hypothermia by Intravenous Infusion of Ice-Cold Fluids After Hospital Arrival in Comatose Survivors of Out-of-Hospital Cardiac Arrest With Initial Shockable Rhythm.

BACKGROUND: The effect of in-hospital rapid cooling by intravenous ice-cold fluids for comatose survivors of out-of-hospital cardiac arrest (OHCA) is unclear.Methods and Results:From the J-PULSE-HYPO study registry, data for 248 comatose survivors with return of spontaneous circulation (ROSC) who were treated with therapeutic hypothermia (34℃ for 12-72 h) after witnessed shockable OHCA were extracted. Patients were divided into 2 groups by the median collapse-to-ROSC interval (18 min), and then into 2 groups by cooling method (rapid cooling by intravenous ice-cold fluids vs. standard cooling). The primary endpoint was favorable neurological outcome (Cerebral Performance Category of 1 or 2) at 30 days after OHCA. In the whole cohort, the shorter collapse-to-ROSC interval group had significantly higher favorable neurological outcome than the longer collapse-to-ROSC interval group (78.2% vs. 46.8%, P<0.001). In the shorter collapse-to-ROSC interval group, no significant difference was observed in favorable neurological outcome between the 2 cooling groups (rapid cooling group: 79.4% vs. standard cooling group: 77.0%, P=0.75). In the longer collapse-to-ROSC interval group, however, favorable neurological outcome was significant higher in the rapid cooling group than in the standard cooling group (60.7% vs. 33.3%, P<0.01) and the adjusted odds ratio after rapid cooling was 3.069 (95% confidence interval 1.423-6.616, P=0.004). CONCLUSIONS: In-hospital rapid cooling by intravenous ice-cold fluids improved neurologically intact survival in comatose survivors whose collapse-to-ROSC interval was delayed over 18 min after shockable OHCA.

Reality of traffic injuries attributable to preceding decreased level of consciousness.

AIM: Although decreased level of consciousness (DLOC) while driving may lead to serious accidents involving drivers and people around them, including passengers and pedestrians, few studies have assessed traffic injuries attributable to preceding DLOC. We aimed to identify factors suggestive of a DLOC preceding traffic injury during initial examination. METHODS: This study included 193 drivers who were brought to our facility during the 1-year period from January to December 2018. The drivers were divided into those with and without DLOC for comparison and analysis. Data on age, sex, causes of DLOC, and medical history were retrospectively reviewed from medical records. RESULTS: Of these 193 drivers, 58 (30.1%) had experienced preceding DLOC. The following factors suggested possible episodes of preceding DLOC: a single-vehicle accident (odds ratio [OR] 3.59; 95% confidence interval [CI] 1.76-7.34; P < 0.001) and histories of hypertension (OR 2.64; 95% CI 1.13-6.15; P = 0.0248) and psychiatric disorders (OR 3.49; 95% CI 1.08-11.3; P = 0.0370). The causes of DLOC were endogenous diseases in 20 drivers (34.3%), dozing off episodes in 19 (32.8%), and acute alcohol intoxication in 11 (19.0%). CONCLUSION: Before traffic accidents, 30.1% of drivers experienced DLOC. Single-vehicle accidents and histories of hypertension and psychiatric disorders were factors suggestive of preceding DLOC.

A System That Uses Advanced Automatic Collision Notification Technology to Dispatch Doctors to Traffic Accidents by Helicopter: The First 4 Cases.

INTRODUCTION: To increase survival rates of patients with severe trauma from road traffic accidents, Japan launched the D-Call Net (DCN) system, which utilizes advanced automatic collision notification technology to dispatch doctors by helicopter. The DCN system began in November 2015 and, as of October 2019, has dispatched doctors 4 times. CASES: Case 1-Canceled because trauma was mild. Case 2-Doctor made contact with 2 patients with moderate trauma 29 minutes earlier than would have occurred conventionally. This was the first case in the world to use automotive engineering data to dispatch a doctor to a patient. Case 3-An accident involving 3 severely injured patients activated DCN, enabling doctor-patient contact 20 minutes earlier than would have been possible conventionally. Case 4-DCN was ineffective. DISCUSSION: According to 2008 data from Chiba Prefecture, in accidents where victims sustain severe trauma, the interval from accident occurrence to hospital arrival was 67 minutes, even when doctors were dispatched by air ambulance (Doctor-Heli [DH]). Use of accident information for faster doctor dispatch effectively improved survival rates. An algorithm was developed to use accident information to assess trauma severity (severity probability). DCN dispatches doctors by using data, including information on accident site and severity probability, which are sent to smartphones of doctors, thereby reducing the interval from accident to DH request by approximately 17 minutes. DCN is the first system in the world to use automotive engineering information for faster doctor dispatch to traffic accident sites. The system is crucial for improving survival rates and mitigating the aftereffects of traffic accidents.

Thoracoabdominal Compression Model of Traumatic Asphyxia to Identify Mechanisms of Respiratory Failure in Fatal Crowd Accidents.

BACKGROUND: Traumatic asphyxia is a major cause of death in fatal crowd disasters, but the relationships between compression site, load magnitude, load time, and medical outcomes are unclear. This study estimated thoracoabdominal compression conditions (load magnitude, load time) that could result in respiratory failure in adults. METHODS: Eight load patterns-A (chest load: 0 kg, abdominal load: 10 kg), B (0, 20), C (10, 0), D (10, 10), E (10, 20), F (20, 0), G (20, 10), and H (20, 20)-were applied to 14 healthy women. Blood pressure, heart rate, respiratory rate, SpO2, tidal volume, vital capacity, respiratory phase, and modified Borg dyspnea score were measured over time. Breathing Intolerance Index (BITI) was also calculated. RESULTS: Vital capacity decreased in patterns C, D, E, F, G, and H. BITI reached the critical range of ≥0.15 (at which respiratory failure occurs after about 45 min) after 14 min in pattern G and 2 min in pattern H. A vital capacity ≤1.85 L and a modified Borg scale score ≥8.3 corresponded to a BITI of ≥0.15 and were regarded as equivalent to reaching the critical range. Furthermore, change in chest load was positively correlated with BITI when abdominal load remained constant. CONCLUSIONS: In women, respiratory failure can occur within 1 h from respiratory muscle fatigue, even when total thoracoabdominal load is only about 60% of body weight. A vital capacity ≤1.85 L and modified Borg scale score ≥8.3 can be regarded as indices for predicting respiratory failure.

Association between rewarming duration and neurological outcome in out-of-hospital cardiac arrest patients receiving therapeutic hypothermia.

AIM: The European Resuscitation Council guidelines recommend a slow rate of rewarming of 0.25 °C/h-0.5 °C/h for out-of-hospital cardiac arrest (OHCA) patients receiving therapeutic hypothermia (TH). Conversely, a very slow rewarming of 1 °C/day is generally applied in Japan. The rewarming duration ranged from less than 24 h up to more than 50 h. No randomized control trials have examined the optimal rewarming speed for TH in OHCA patients. Therefore, we examined the association between the rewarming duration and neurological outcomes in OHCA patients who received TH. METHODS: This study was a secondary analysis of the Japanese Population-based Utstein-style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia (J-PULSE-HYPO) study registry, a multicenter prospective cohort study. Patients suffering from OHCA who received TH (target temperature, 34 °C) after the return of spontaneous circulation from 2005 to 2011 in 14 hospitals throughout Japan were enrolled. The rewarming duration was defined as the time from the beginning of rewarming at a target temperature of 34 °C until reaching 36 °C. The primary outcome was an unfavorable neurological outcome at hospital discharge, i.e., a cerebral performance category of 3-5. RESULTS: The J-PULSE-HYPO study enrolled 452 OHCA patients. Of these, 328 were analyzed; 79.9% survived to hospital discharge, of which 56.4% had a favorable neurological outcome. Multivariable logistic regression analysis revealed that the rewarming duration was independently associated with unfavorable neurological outcomes [odds ratio (per 5 h), 0.89; 95% confidence interval, 0.79-0.99; p =  0.032]. CONCLUSION: A longer rewarming duration was significantly associated with and was an independent predictor of favorable neurological outcomes in OHCA patients who received TH.

The Impact of Heart Rate Response During 48-Hour Rewarming Phase of Therapeutic Hypothermia on Neurologic Outcomes in Out-of-Hospital Cardiac Arrest Patients.

OBJECTIVES: Bradycardia during therapeutic hypothermia has been reported to be a predictor of favorable neurologic outcomes in out-of-hospital cardiac arrests. However, bradycardia occurrence rate may be influenced by the target body temperature. During therapeutic hypothermia, as part of the normal physiologic response, heart rate decreases in the cooling phase and increases during the rewarming phase. We hypothesized that increased heart rate during the rewarming phase is another predictor of favorable neurologic outcomes. To address this hypothesis, the study aimed to examine the association between heart rate response during the rewarming phase and neurologic outcomes in patients having return of spontaneous circulation after out-of-hospital cardiac arrest. DESIGN: A secondary analysis of the Japanese Population-based Utstein style study with defibrillation and basic/advanced Life Support Education and implementation-Hypothermia registry, which was a multicenter prospective cohort study. SETTING: Fourteen hospitals throughout Japan. PATIENTS: Patients suffering from out-of-hospital cardiac arrest who received therapeutic hypothermia after the return of spontaneous circulation from 2005 to 2011. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: This study enrolled 452 out-of-hospital cardiac arrest patients, of which 354 were analyzed, and 80.2% survived to hospital discharge, of which 57.3% had a good neurologic outcome. Heart rate response was calculated using heart rate data recorded during therapeutic hypothermia in the abovementioned registry. Heart rate response in the rewarming phase (heart rate response-rewarming) was calculated as follows: (heart rate [post rewarming]-heart rate [pre rewarming])/heart rate (pre rewarming) × 100. The primary outcome was an unfavorable neurologic outcome at hospital discharge, that is, a Cerebral Performance Category of 3-5. Multivariable logistic regression analysis was performed to determine the association between heart rate response-rewarming and unfavorable neurologic outcomes. Multivariable logistic regression analysis showed that heart rate response-rewarming was independently associated with unfavorable outcomes (odds ratio [per 10% change], 0.86; 95% CI, 0.78-0.96; p = 0.004). CONCLUSIONS: Increased heart rate in the approximately 48-hour rewarming phase during therapeutic hypothermia was significantly associated with and was an independent predictor of favorable neurologic outcomes during out-of-hospital cardiac arrest.

Aeromedical Transport Operations Using Helicopters during the 2016 Kumamoto Earthquake in Japan.

More than 6,000 people died in the Great Hanshin (Kobe) Earthquake in 1995, and it was later reported that there were around 500 preventable trauma deaths. In response, the Japanese government developed the helicopter emergency medical service in 2001, known in Japan as the "Doctor-Heli" (DH), which had 46 DHs and 2 private medical helicopters as of April 2016. DHs transport physicians and nurses to provide pre-hospital medical care at the scene of medical emergencies. Following lessons learned in the Great East Japan Earthquake in 2011, a research group in the Ministry of Health, Labour and Welfare developed a command and control system for the DH fleet as well as the Disaster Relief Aircraft Management System Network (D-NET), which uses a satellite communications network to monitor the location of the fleet and weather in real-time during disasters. During the Kumamoto Earthquake disaster in April 2016, 75 patients were transported by 13 DHs and 1 private medical helicopter in the first 5 days. When medical demand for the DHs exceeded supply, 5 patients, 8 patients, and 1 patient were transported by Self-Defense Force, Fire Department, and Coast Guard helicopters, respectively. Of the 89 patients who were transported, 30 (34%) had trauma, 3 (3%) had pulmonary embolisms caused by sleeping in vehicles, and 17 (19%) were pregnant women or newborns. This was the first time that the command and control system for aeromedical transport and D-NET, established after the Great East Japan Earthquake in 2011, were operated in an actual large-scale disaster. Aeromedical transport by DHs and helicopters belonging to several other organizations was accomplished smoothly because the commanders of the involved organizations could communicate directly with each other in person within the Aviation Coordination Section of the prefectural government office. However, ongoing challenges in the detailed operating methods for aeromedical transport were highlighted and include improving shared knowledge and training across the organizational framework. These are particularly important issues to address given the Nankai Trough and Tokyo inland earthquakes that are predicted for the near future in Japan.

Serious injury prediction algorithm based on large-scale data and under-triage control.

The present study was undertaken to construct an algorithm for an advanced automatic collision notification system based on national traffic accident data compiled by Japanese police. While US research into the development of a serious-injury prediction algorithm is based on a logistic regression algorithm using the National Automotive Sampling System/Crashworthiness Data System, the present injury prediction algorithm was based on comprehensive police data covering all accidents that occurred across Japan. The particular focus of this research is to improve the rescue of injured vehicle occupants in traffic accidents, and the present algorithm assumes the use of an onboard event data recorder data from which risk factors such as pseudo delta-V, vehicle impact location, seatbelt wearing or non-wearing, involvement in a single impact or multiple impact crash and the occupant's age can be derived. As a result, a simple and handy algorithm suited for onboard vehicle installation was constructed from a sample of half of the available police data. The other half of the police data was applied to the validation testing of this new algorithm using receiver operating characteristic analysis. An additional validation was conducted using in-depth investigation of accident injuries in collaboration with prospective host emergency care institutes. The validated algorithm, named the TOYOTA-Nihon University algorithm, proved to be as useful as the US URGENCY and other existing algorithms. Furthermore, an under-triage control analysis found that the present algorithm could achieve an under-triage rate of less than 10% by setting a threshold of 8.3%.

Impact of urgent resuscitative surgery for life-threatening torso trauma.

PURPOSE: This study investigated the advantages of performing urgent resuscitative surgery (URS) in the emergency department (ED); namely, our URS policy, to avoid a delay in hemorrhage control for patients with severe torso trauma and unstable vital signs. METHODS: We divided 264 eligible cases into a URS group (n = 97) and a non-URS group (n = 167) to compare, retrospectively, the observed survival rate with the predicted survival using the Trauma and Injury Severity Score (TRISS). RESULTS: While the revised trauma score and the injury severity score were significantly lower in the URS group than in the non-URS group, the observed survival rate was significantly higher than the predicted rate in the URS (48.5 vs. 40.2%; p = 0.038). URS group patients with a systolic blood pressure (SBP) <90 mmHg and a Glasgow coma scale (GCS) score of ≥9 had significantly higher observed survival rates than predicted survival rates (0.433 vs. 0.309, p = 0.008), (0.795 vs. 0.681, p = 0.004). The implementation of damage control surgery (DCS) was found to be a significant predictor of survival (OR 5.23, 95% CI 0.113-0.526, p < 0.010). CONCLUSION: The best indications for the URS policy are an SBP <90 mmHg, a GCS ≥9 on ED arrival, and/or the need for DCS. By implementing our URS policy, satisfactory survival of patients requiring immediate hemostatic surgery was achieved.

Dispatch of Helicopter Emergency Medical Services Via Advanced Automatic Collision Notification.

BACKGROUND: Advanced automatic collision notification (AACN) is a system for predicting occupant injury from collision information. If the helicopter emergency medical services (HEMS) physician can be alerted by AACN, it may be possible to reduce the time to patient contact. OBJECTIVE: The purpose of this study was to validate the feasibility of early HEMS dispatch via AACN. METHODS: A full-scale validation study was conducted. A car equipped with AACN was made to collide with a wall. Immediately after the collision, the HEMS was alerted directly by the operation center, which received the information from AACN. Elapsed times were recorded and compared with those inferred from the normal, real-world HEMS emergency request process. RESULTS: AACN information was sent to the operation center only 7 s after the collision; the HEMS was dispatched after 3 min. The helicopter landed at the temporary helipad 18 min later. Finally, medical intervention was started 21 min after the collision. Without AACN, it was estimated that the HEMS would be requested 14 min after the collision by fire department personnel. The start of treatment was estimated to be at 32 min, which was 11 min later than that associated with the use of AACN. CONCLUSIONS: The dispatch of the HEMS using the AACN can shorten the start time of treatment for patients in motor vehicle collisions. This study demonstrated that it is feasible to automatically alert and activate the HEMS via AACN.

The Pedicled Omental Flap Technique for Treating Extensive Defects or Soft-Tissue Infection of the Pelvic Area: A Report of 2 Cases.

Severe trauma injuries, such as open pelvic fractures and degloving injuries, have recently become salvageable. However, extensive soft-tissue defects often remain and can lead to disuse atrophy of the extremities, prolonged hospital stays, and numerous other problems. Such injuries can be easily and effectively treated by a general trauma surgeon performing the pedicled omental flap technique. We report on 2 highly diverse and complicated cases of soft-tissue defect that were both successfully treated with this technique. One case was an extensive right-sided defect of the pelvic soft-tissue in a 20-year-old woman. The other case was in a 55-year-old man who underwent emergency artificial vessel replacement surgery for a femoral artery tear with severe damage to the surrounding muscle. Although the surgery was successful, a methicillin-resistant Staphylococcus aureus infection developed around the artificial vessel 10 days after surgery. In both cases, the pedicled omental flap technique was successfully performed and yielded epithelization without serious infection and with the infection subsiding with wound-area healing. To our knowledge, the pedicled omental flap technique has rarely been used to treat severe trauma, and our results suggest its usefulness for both preventing infection in large wounds and healing infected wounds.

Effect of Admission Glasgow Coma Scale Motor Score on Neurological Outcome in Out-of-Hospital Cardiac Arrest Patients Receiving Therapeutic Hypothermia.

BACKGROUND: Because the initial (on admission) Glasgow Coma Scale (GCS) examination has not been fully evaluated in comatose survivors of cardiac arrest (CA) who receive therapeutic hypothermia (TH), the aim of the present study was to determine any association between the admission GCS motor score and neurologic outcomes in patients with out-of-hospital CA who receive TH. METHODS AND RESULTS: In the J-PULSE-HYPO study registry, patients with bystander-witnessed CA were eligible for inclusion. Patients were divided into 3 groups based on GCS motor score (1, 2-3, and 4-5) to assess various effects on neurologic outcome. Univariate and multivariate analyses were performed to identify independent predictors of good neurologic outcome at 90 days. Of 452 patients, 302 were enrolled. There was a significant difference among the 3 patient groups with regard to neurologic outcome at 90 days in the univariate analysis. Multiple logistic regression analyses showed that the GCS motor score on admission, age >65 years, bystander cardiopulmonary resuscitation, the time from collapse to return of spontaneous circulation, and pupil size <4 mm were independent predictors of a good neurologic outcome at 90 days in cases of CA (GCS motor score, 4-5: odds ratio, 8.18; 95% confidence interval: 1.90-60.28; P<0.01). CONCLUSIONS: GCS motor score is an independent predictor of good neurologic outcome at 90 days in patients sustaining out-of-hospital CA who receive TH.

Effectiveness of lower target temperature therapeutic hypothermia in post-cardiac arrest syndrome patients with a resuscitation interval of ≤30 min.

BACKGROUND: Therapeutic hypothermia (TH) is a standard strategy to reduce brain damage in post-cardiac arrest syndrome (PCAS) patients. However, it is unknown whether the target temperature should be adjusted for PCAS patients in different states. METHODS: Participants in the J-PULSE-Hypo study database were divided into lower (32.0-33.5 °C; Group L) or moderate (34.0-35.0 °C; Group M) temperature groups. Primary outcome was a favourable neurological outcome (proportion of patients with a Glasgow-Pittsburgh Cerebral Performance Category [CPC] of 1-2 on day 30). We compared between the two groups and in subgroups of patients divided by age and resuscitation interval (interval from collapse to return of spontaneous circulation) by propensity score (PS) analysis. RESULTS: Overall, 467 participants were analysed. The proportions of patients with favourable neurological outcomes were as follows (Group L vs. Group M) (OR; Odds ratio): all patients, 64 % (n = 42) vs. 55 % ((n = 424) (PS; OR 1.381 (0.596-3.197)), P = 0.452) and resuscitation interval ≤ 30 min, 88 % (n = 24) vs. 64 % ((n = 281) (PS; OR 7.438 (1.769-31.272)), P = 0.007). CONCLUSIONS: PCAS patients with a resuscitation interval of <30 min may be candidates for TH with a target temperature of <34 °C. TRIAL REGISTRATION: University Hospital Medical Information Network (UMIN) Clinical Trials Registry UMIN000001935; available at: https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000002348&language=J.

Evaluation of the safety and feasibility of resuscitative endovascular balloon occlusion of the aorta.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is one of the ultimately invasive procedures for managing a noncompressive torso injury. Since it is less invasive than resuscitative open aortic cross-clamping, its clinical application is expected. METHODS: We retrospectively evaluated the safety and clinical feasibility of REBOA (intra-aortic occlusion balloon, MERA, Tokyo, Japan) using the Seldinger technique to control severe hemorrhage. Of 5,230 patients admitted to our trauma center in Japan from 2007 to 2013, we included 24 who underwent REBOA primarily. The indications for REBOA were a pelvic ring fracture or hemoperitoneum with hemodynamically instability and impending cardiac arrest. Emergency hemostasis was performed during REBOA in all patients. RESULTS: All 24 patients had a blunt injury, the median age was 59 (interquartile range, 41-71 years), the median Injury Severity Score (ISS) was 47 (interquartile range, 37-52), the 30-day survival rate was 29.2% (n = 7), and the median probability survival rate was 12.5%. Indications for REBOA were hemoperitoneum and pelvic ring fracture in 15 cases and overlap in 8 cases. In 10 cases of death, the balloon could not be deflated in 5 cases. In 19 cases in which the balloon was deflated, the median duration of aortic occlusion was shorter in survivors than in deaths (21 minutes vs. 35 minutes, p = 0.05). The mean systolic blood pressure was significantly increased by REBOA (from 53.1 [21] mm Hg to 98.0 [26.6] mm Hg, p < 0.01). There were three cases with complications (12.5%), one external iliac artery injury and two lower limb ischemias in which lower limb amputation was necessary in all cases. Acute kidney injury developed in all three cases, but failure was not persistent. CONCLUSION: REBOA seems to be feasible for trauma resuscitation and may improve survivorship. However, the serious complication of lower limb ischemia warrants more research on its safety. LEVEL OF EVIDENCE: Therapeutic/care management, level V.

Preventable trauma deaths after traffic accidents in Chiba Prefecture, Japan, 2011: problems and solutions.

INTRODUCTION: The incidence of preventable trauma death in the current Japanese emergency medical system remains high. The present study aimed to determine rates of clearly preventable and possibly preventable trauma deaths due to traffic accidents in Chiba Prefecture, Japan, and to consider associated problems and solutions. MATERIALS AND METHODS: During 2011, 175 victims died after traffic accidents in Chiba Prefecture. Of these, the deaths of 69 persons who had vital signs at the time of emergency medical service contact were classified as clearly preventable, possibly preventable, or not preventable through the peer review discussion. We also examined problems associated with deaths that were clearly preventable or possibly preventable. RESULTS: Of the 69 deaths, 9 (13%) were classified as clearly preventable, 11 (16%) as possibly preventable, and 49 (71%) as not preventable. Of the 20 clearly or possibly preventable deaths (each death potentially comprising multiple problems), 5 were related to selection of the hospital before hospital arrival, 4 to problems with regional emergency medical systems, and 15 to inappropriate hemodynamic management, including transfusion and delayed (or not attempted) hemostasis in the hospital. DISCUSSION: Problems of these 20 deaths showed that appropriate triage at the scene, centralization of patients with severe trauma, and trauma centers are necessary in Japan. Under-triage before arrival at the hospital was related to clearly and possibly preventable deaths. Upgrading the triage category for victims with torso injury must be considered. Not all emergency critical care centers in Japan are able to provide severe trauma care. Preventable trauma deaths occur even in some emergency critical care centers; therefore, we need centralization of severe trauma patients from wider area to reduce the incidence of preventable trauma death.

Development of an educational program for the helicopter emergency medical services in Japan.

INTRODUCTION: The Japanese helicopter emergency medical service (HEMS) system provides advanced prehospital treatment at the scene. The education of the dispatched HEMS physicians is important for guaranteeing the quality of medical and safety management, but there is no nationally established training program. This study aimed to determine the validity of the HEMS educational program developed by our team. METHODS: A 3-step educational program was designed for HEMS trainees: step 1, 20 HEMS missions as an observer; step 2, 80 missions of on-the-job training; and step 3, certifying examination conducted by a supervisor. As an evaluation standard, scene time, defined as time from landing at the scene to taking off for a hospital, was determined retrospectively. RESULTS: For trainees, scene time was significantly longer (16.3 ± 5.4 min, 95% CI 15.5-17.1) than for experts (doctors who completed >200 HEMS missions; 15.2 ± 6.7 min, 95% CI 14.7-15.8; P = 0.040) but was significantly shorter than for doctors trained before establishment of the HEMS program (17.5 ± 7.0 min, 95% CI 16.9-18.2; P = 0.030). In cases of trauma or intrinsic disease, there was no significant difference in scene time between trainees (17.4 ± 5.6 min and 14.9 ± 4.8 min, respectively) and experts (16.4 ± 7.8 min and 14.2 ± 5.5 min, respectively). CONCLUSION: The finding that scene time was shortened for program trainees demonstrates the validity of our HEMS educational program. The quality of HEMS missions will be better ensured through this educational system.