Successful interventional management of mediastinal hematoma caused by thyroid ima artery injury.

BACKGROUND: The thyroid ima artery (ThIA) is a rare anatomical anomaly, commonly branching from the brachiocephalic artery. Thyroid ima artery injury can cause severe mediastinal hematoma because its descending branch extends into the mediastinum. CASE PRESENTATION: A 91-year-old man presented with syncope after a motor vehicle accident. A bruise on the chest was evident. Contrast-enhanced computed tomography revealed a massive mediastinal hematoma with signs of active hemorrhage. Injury to a descending branch of the ThIA was indicated. Transcatheter arterial embolization (TAE) was successful in stopping the bleeding. CONCLUSIONS: Although a ThIA injury is rare, it can cause serious mediastinal hematoma. Thyroid ima artery injury should be considered as a cause of traumatic mediastinal hematoma. Transcatheter arterial embolization for traumatic ThIA injury is considered a safe and effective treatment.

Reversible brain imaging findings with a severe neurological prognosis of neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is a rare but life-threatening disorder associated with the use of neuroleptic drugs, and is characterized by fever, altered mental status, muscle rigidity, autonomic instability, myoclonus, elevated creatine kinase levels, rhabdomyolysis, and leukocytosis. Previous reports have shown that most patients with neuroleptic malignant syndrome recover without neurologic sequelae. Some patients with neuroleptic malignant syndrome show reversible magnetic resonance imaging (changes in the brain. The severe neurological impairments do not persist in neuroleptic malignant syndrome patients with reversible lesions. Here, we describe a 66-year-old Japanese woman who was diagnosed with septic shock secondary to obstructive pyelonephritis. She was administered haloperidol for delirium and developed neuroleptic malignant syndrome. Magnetic resonance imaging of the brain showed diffuse hyperintense signals in the cerebellar cortex, cerebellar dentate nucleus, superior cerebellar peduncle, and thalamus on T2-weighted imaging or fluid-attenuated inversion recovery, and in the bilateral substantia nigra and bilateral globus pallidus on diffusion-weighted imaging. Subsequently, the signal intensities of the cerebellar and thalamic lesions diminished and the basal ganglia lesions disappeared, but the severe neurologic sequelae remained. The cerebellum is reportedly particularly sensitive to thermal damage because Purkinje cells are believed to be vulnerable to heat. Although brain imaging studies revealed reversible changes, her disturbance of consciousness was prolonged. Therefore, brain magnetic resonance imaging findings might not reflect the neurologic prognosis in patients with neuroleptic malignant syndrome.

Streptococcus Pneumoniae-associated Thrombotic Microangiopathy in an Immunosuppressed Adult.

A 62-year-old male who was receiving prednisolone and methotrexate for scleroderma and rheumatoid arthritis complained of diarrhea and vomiting, and was transferred to our hospital for detailed examination and treatment of renal dysfunction and thrombocytopenia. Hemolytic anemia and crushed erythrocytes were found during the patient's course; therefore, we suspected thrombotic microangiopathy (TMA). His ADAMTS13 activity was 60.3% and his ADAMTS13 inhibitor was under 0.5. In addition, his blood culture was positive for Streptococcus pneumoniae, and we finally diagnosed Streptococcus pneumoniae-associated TMA (pTMA). The patient was treated with antibiotics and hemodialysis. The patient recovered and was discharged on the 45th hospital day. Adult pTMA cases are remarkably rare. We herein report a successfully treated adult case of pTMA.

Levels of Catecholamines in the Plasma of Patients with Cardiopulmonary Arrest.

So far, there remains a controversy regarding the efficacy of epinephrine (Ep) in patients with cardiopulmonary arrest (CPA). In this study, we evaluated the importance of the plasma levels of catecholamines prior to the administration of Ep in patients with CPA. Patients with out-of-hospital cardiac arrest (OHCA) who were transferred to Gunma University Hospital were enrolled prospectively between July 2014 and July 2017. The levels of catecholamines [Ep, norepinephrine (NEp), and dopamine] and vasopressin (antidiuretic hormone) in the plasma were measured using blood samples of cardiogenic patients with OHCA not treated with Ep. Patients were divided into two groups: the return of spontaneous circulation [ROSC (+) ] group and the no return of spontaneous circulation [ROSC (-) ] group. The plasma levels of these agents and the conditions of resuscitation were compared between these two groups. 48 patients with cardiogenic CPA had not been treated with Ep prior to obtaining the blood samples. The ROSC (+) and ROSC (-) groups included 14 and 34 patients, respectively. The frequency of prehospital defibrillation was significantly higher in the ROSC (+) group. However, the prehospital resuscitation time was significantly shorter in the ROSC (+) group. Moreover, the levels of Ep and NEp in the plasma were significantly lower in the ROSC (+) group. The increased levels of Ep in the plasma may not be associated with the acquisition of ROSC in patients with cardiogenic CPA.

Report of Four Cases with Equestrian Injury: Therapeutic Approach and Outcome.

Equestrianism is associated with a risk of severe trauma due to falls and/or direct injury from the horse, depending on the mechanism of injury. This article presents four cases of equestrian injury treated in Gunma University Hospital: Case 1: hepatic injury (fall and kick by the horse); Case 2: left hemopneumothorax and pulmonary contusion with multiple rib fractures (fall and trampling by the horse); Case 3: lumbar compression fracture (fall); and Case 4: scrotum injury (horse bite). Equestrian injuries may be high-energy traumas. Therefore, adhering to relevant primary care guidelines may prevent mortality by trauma.

Successful Endovascular Therapy in an Elderly Patient with Severe Hemorrhage Caused by Traumatic Injury.

An 85-year-old female suffered pelvic fracture, multiple rib fractures, right hemopneumothorax, and blunt abdominal aortic injury in a traffic accident. After transfer to our hospital, transcatheter arterial embolization (TAE) was performed immediately for hemorrhage from the bilateral internal iliac arteries. Enhanced computed tomography (CT) after TAE showed an increase of hematoma and extravasation at the bifurcation of the abdominal aorta. Therefore, emergency abdominal endovascular aortic repair was performed on the same day. On the 3rd day after transfer, metabolic acidosis worsened suddenly, and enhanced CT revealed intestinal necrosis. Emergency surgery for the intestinal necrosis was performed. The patient was transferred to the previous hospital on the 31st day after transfer. Endovascular treatment is useful for elderly patients with severe trauma. However, the preservation and/or reconstruction of the blood flow to important organs should be monitored.

Can the Wish to Receive Intensive Treatment in Elderly Patients with Respiratory Tract Infection Be Predicted?

Objective Almost no Japanese elderly patients have an advance directive (AD). Our aim was to determine whether or not the wish to receive intensive care in elderly patients with respiratory tract infection could be predicted from the prehospital data. Methods In this retrospective study, we reviewed patients ≥65 years of age with respiratory tract infection who had been transferred to our hospital by ambulance between September 2014 and August 2016. The patients were divided into two groups according to whether or not they wished to receive intensive treatment. We placed patients without a wish to receive intensive treatments (WITs) in Group A and patients with a WITs in Group B. We then analyzed parameters that could be determined in the prehospital phase and compared the findings between the groups. Results Thirty-seven patients were in Group A, and 67 patients were in Group B. None of the patients in this study had an AD. There were significant differences in the age, rate of residence in an extended care facility, frequency of inability to care for oneself fully, frequency of dementia, number of prescribed drugs, and Glasgow coma scale (GCS) on a univariate analysis. A logistic regression analysis showed that the inability to care for oneself fully [odds ratio (OR): 4.521, 95% confidence interval (CI): 2.024-10.096, p<0.001] and a low GCS (OR 0.885, 95%CI 0.838-0.935, p<0.001) were related to a WITs. Conclusion Elderly patients who are unable to care for themselves and who have a low GCS in the prehospital stage are likely not to want intensive treatment.

Efficacy of the Treatment of Elderly Trauma Patients Requiring Intensive Care.

PURPOSE: To evaluate the effectiveness of intensive care for the elderly trauma patients aged 80 years and older. METHODS: Trauma patients admitted to the intensive care unit (ICU) through the emergency room (ER) at our hospital between January 2013 and December 2016 were analyzed. Patients were divided into two groups: patients aged 80 and older (group E) and <80 years old (group Y). Clinical courses and the total treatment costs were compared between the two groups. Data are shown as median (interquartile range). RESULTS: A hundred and seven trauma patients were included in the study. There were 26 patients in group E and 81 patients in group Y. There was no significant difference in Injury Severity Score (ISS) (group E, 19 (13, 32); group Y, 17 (14, 25); p=0.708); however, the probability of survival (Ps) was significantly lower in group E (group E, 0.895 (0.757, 0.950); group Y, 0.955 (0.878, 0.986); p=0.004). The duration of ICU stay (days) was significantly longer in group E (10 (5, 23)) than in group Y (4 (3, 9); p=0.001), and the total hospital stay (days) was longer in group E (33 (13, 57)) than in group Y (22 (12, 42); p=0.179). The hospital mortality was higher in group E (11.5%) than in group Y (6.2%) without a significant difference (p=0.365). The total treatment costs were significantly higher in group E ($23,558 (12,456, 42,790) with $1 = ¥110.57) than in group Y ($16,538 (7,412, 25,422); p=0.023). CONCLUSIONS: Elderly trauma patients require longer-term treatment including ICU stay and greater cost with higher hospital mortality compared with young trauma patients.

Post-traumatic hypopituitarism: report of a child case.

Case: We report a case of post-traumatic hypopituitarism in a 9-year-old boy who was injured in a car accident. Outcome: Post-traumatic hypopituitarism might be caused by moderate to severe head trauma, and while this possibility has recently drawn attention in adults, few reports are available regarding children. Our patient experienced head and facial injury, resulting in post-traumatic hypopituitarism. Six hours after injury he suffered from diabetes insipidus and hormone replacement therapy was started. On day 12 he underwent facial fracture reduction under general anesthesia. On day 24 he was discharged from the hospital. One year after the injury, secretory function and water dehydration tests suggested the possibility of post-traumatic hypopituitarism. Conclusion: We experienced a child case of post-traumatic hypopituitarism. Emergency physicians should pay attention to the possibility of post-traumatic hypopituitarism in cases of traumatic brain injury.

Low-dose immunoglobulin G is not associated with mortality in patients with sepsis and septic shock.

BACKGROUND: The administration of low-dose intravenous immunoglobulin G (IVIgG) (5 g/day for 3 days; approximate total 0.3 g/kg) is widely used as an adjunctive treatment for patients with sepsis in Japan, but its efficacy in the reduction of mortality has not been evaluated. We investigated whether the administration of low-dose IVIgG is associated with clinically important outcomes including intensive care unit (ICU) and in-hospital mortality. METHODS: This is a post-hoc subgroup analysis of data from a retrospective cohort study, the Japan Septic Disseminated Intravascular Coagulation (JSEPTIC DIC) study. The JSEPTIC DIC study was conducted in 42 ICUs in 40 institutions throughout Japan, and it investigated associations between sepsis-related coagulopathy, anticoagulation therapies, and clinical outcomes of 3195 adult patients with sepsis and septic shock admitted to ICUs from January 2011 through December 2013. To investigate associations between low-dose IVIgG administration and mortalities, propensity score-based matching analysis was used. RESULTS: IVIgG was administered to 960 patients (30.8%). Patients who received IVIgG were more severely ill than those who did not (Acute Physiology and Chronic Health Evaluation (APACHE) II score 24.2 ± 8.8 vs 22.6 ± 8.7, p < 0.001). They had higher ICU mortality (22.8% vs 17.4%, p < 0.001), but similar in-hospital mortality (34.4% vs 31.0%, p = 0.066). In propensity score-matched analysis, 653 pairs were created. Both ICU mortality and in-hospital mortality were similar between the two groups (21.0% vs 18.1%, p = 0.185, and 32.9% vs 28.6%, p = 0.093, respectively) using generalized estimating equations fitted with logistic regression models adjusted for other therapeutic interventions. The administration of IVIgG was not associated with ICU or in-hospital mortality (odds ratio (OR) 0.883; 95% confidence interval (CI) 0.655-1.192, p = 0.417, and OR 0.957, 95% CI, 0.724-1.265, p = 0.758, respectively). CONCLUSIONS: In this analysis of a large cohort of patients with sepsis and septic shock, the administration of low-dose IVIgG as an adjunctive therapy was not associated with a decrease in ICU or in-hospital mortality. TRIAL REGISTRATION: University Hospital Medical Information Network Individual Clinical Trials Registry, UMIN-CTR000012543 . Registered on 10 December 2013.

Transcatheter Arterial Embolization of a Lumbar Artery Injury with Traumatic Aortic Dissection.

Whole-body-enhanced computed tomography of a septuagenarian woman hit by a truck revealed a traumatic aortic dissection (Stanford B) and arterial bleeding from the right lumbar artery in the right iliopsoas muscle. Angiography revealed an active arterial extravasation from a false lumen of the left lumbar artery. We performed a transcatheter arterial embolization (TAE) of the right lumbar artery. After fenestration of the intimal flap, the left lumbar artery was successfully selected and embolized; the patient's clinical condition subsequently stabilized. This is the first report of successful treatment of a lumbar artery injury with a traumatic aortic dissection by a TAE.

The Significance of Strong Ion Gap for Predicting Return of Spontaneous Circulation in Patients with Cardiopulmonary Arrest.

Useful parameters that can predict return of spontaneous circulation (ROSC) in patients with cardiopulmonary arrest (CPA) have not been established. We previously reported the usefulness of anion gap (AG) and albumin-corrected anion gap (ACAG) calculated from a blood sample obtained on arrival at the hospital for the prediction of ROSC. Otherwise, it has been reported that strong ion gap (SIG), which shows the difference between the levels of fully dissociated cations and anions in the serum, is useful to predict the prognosis of critically ill patients. This was a prospective and observational clinical study. Patients with CPA transferred to the emergency department of our hospital between January 2013 and December 2014 were evaluated. Patients were divided into two groups: patients who obtained ROSC [ROSC(+) group] and those who did not [ROSC(-) group]. We compared AG, ACAG and SIG between the two groups. A total of 170 patients were enrolled. Fifty patients were included in the ROSC(+) group, and the remaining 120 in the ROSC(-) group. Both AG and ACAG were significantly better in the ROSC(+) group; however, there was no significant difference in SIG between the two groups. The area under the receiver operating characteristic curves (AUC) for ROSC of both AG and ACAG were almost the same (0.72 and 0.708, respectively); the AUC of SIG (0.57) was inferior to those of AG and ACAG. Our results suggest that AG and ACAG can better predict ROSC following cardiopulmonary resuscitation (CPR) compared with SIG.

FDP/fibrinogen ratio reflects the requirement of packed red blood cell transfusion in patients with blunt trauma.

PURPOSE: To find factors that predict the requirement of packed red blood cells (pRBC) transfusion in patients with blunt trauma on arrival at the hospital. METHODS: We conducted blood tests in trauma patients whose trauma severity was suspected as being 3 and over in the Abbreviated Injury Scale. Patients were divided into the blood transfusion (BT) and control groups according to the requirement of pRBC transfusion within 24h after arrival. RESULTS: We analyzed 347 patients (BT group, n=14; control group, n=333). On univariate analysis, there were significant differences in Glasgow Coma Scale (GCS), rate of positive FAST (focused assessment with sonography for trauma) finding, hematocrit, international normalized ratio of prothrombin time, activated partial thromboplastin time, fibrinogen (Fib), and level of fibrin degradation products (FDP). On multivariable analysis, positive FAST finding, GCS, Fib, and FDP influenced the requirement of pRBC transfusion. In the area under the receiver operating characteristic curve analysis, Fib and FDP were markers that predicted the requirement of pRBC transfusion. The FDP/Fib ratio had a better correlation with the requirement of pRBC transfusion than FDP or Fib. CONCLUSIONS: The FDP/Fib ratio can be easily measured and may be a predictor of the need for pRBC transfusion.

Antithrombin Supplementation and Mortality in Sepsis-Induced Disseminated Intravascular Coagulation: A Multicenter Retrospective Observational Study.

Supplemental doses of antithrombin (AT) are widely used to treat sepsis-induced disseminated intravascular coagulation (DIC) in Japan. However, evidence on the benefits of AT supplementation for DIC is insufficient. This multicenter retrospective observational study aimed to clarify the effect of AT supplementation on sepsis-induced DIC using propensity score analyses. Data from 3,195 consecutive adult patients admitted to 42 intensive care units for severe sepsis treatment were retrospectively analyzed; 1,784 patients were diagnosed with DIC (n = 715, AT group; n = 1,069, control group). Inverse probability of treatment-weighted propensity score analysis indicated a statistically significant association between AT supplementation and lower in-hospital all-cause mortality (n = 1,784, odds ratio [95% confidence intervals]: 0.748 [0.572-0.978], P = 0.034). However, quintile-stratified propensity score analysis (n = 1,784, odds ratio: 0.823 [0.646-1.050], P = 0.117) and propensity score matching analysis (461 matching pairs, odds ratio: 0.855 [0.649-1.125], P = 0.263) did not show this association. In the early days after intensive care unit admission, the survival rate was statistically higher in the propensity score-matched AT group than in the propensity score-matched control group (P = 0.007). In DIC patients without concomitant heparin administration, similar results were observed. In conclusion, AT supplementation may be associated with reduced in-hospital all-cause mortality in patients with sepsis-induced DIC. However, the statistical robustness of this connection was not strong. In addition, although the number of transfusions needed in patients with AT supplementation increased, severe bleeding complications did not.

Deep Vein Thrombus Occurring Immediately After Blunt Abdominal Trauma.

CASE: A 13-year-old adolescent girl with blunt abdominal injury was transferred to our hospital. Enhanced computed tomography (CT) showed not only retroperitoneal hematoma around the inferior vena cava and left common iliac vein but also thrombus extending from the left common iliac vein to the femoral vein. OUTCOME: Enhanced CT performed on the second day revealed no increase in retroperitoneal hematoma and a new small thrombus in the popliteal vein. Anticoagulant therapy was therefore started with administration of unfractionated heparin. Administration of warfarin was started on the 12th day and heparin administration was stopped on the 14th day. The patient was discharged on the 19th day with continuation of warfarin administration. Enhanced CT performed 10 months after injury showed no thrombus, and the administration of warfarin was then stopped. CONCLUSIONS: She was successfully treated with the appropriate start time and control of anticoagulation therapy based on careful evaluation of her general condition.

Characteristics, treatments, and outcomes of severe sepsis of 3195 ICU-treated adult patients throughout Japan during 2011-2013.

Severe sepsis is a major concern in the intensive care unit (ICU), although there is very little epidemiological information regarding severe sepsis in Japan. This study evaluated 3195 patients with severe sepsis in 42 ICUs throughout Japan. The patients with severe sepsis had a mean age of 70 ± 15 years and a mean Acute Physiology and Chronic Health Evaluation II score of 23 ± 9. The estimated survival rates at 28 and 90 days after ICU admission were 73.6 and 56.3 %, respectively.

Prediction of extravasation in pelvic fracture using coagulation biomarkers.

PURPOSE: To evaluate the usefulness of coagulation biomarkers, which are easy and quick to analyze in emergency settings, for prediction of arterial extravasation due to pelvic fracture. PATIENTS AND METHODS: The medical records of pelvic fracture patients transferred to the emergency department of Gunma University Hospital between December 2009 and May 2015 were reviewed. Patients were divided into two groups, those with (Extra(+)) and without (Extra(-)) arterial extravasation on enhanced CT or angiography. Levels of fibrin degradation products (FDP), D-dimer, fibrinogen, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, systolic blood pressure, heart rate, the Glasgow Coma Scale, pH, base excess, hemoglobin and lactate levels, the pattern of pelvic injury, and injury severity score were measured at hospital admission, and compared between the two groups. Parameters with a significant difference between the two groups were used to construct receiver operating characteristic (ROC) curves. RESULTS: The study included 29 patients with pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most useful parameters for predicting arterial extravasation due to pelvic fracture. FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, and hemoglobin and lactate levels were significantly higher in the Extra(+) group than in the Extra(-) group (FDP, 354.8µg/mL [median] versus 96.6µg/mL; D-dimer, 122.3µg/mL versus 42.1µg/mL; the ratio of FDP to fibrinogen, 3.39 versus 0.42; the ratio of D-dimer to fibrinogen, 1.14 versus 0.18; hemoglobin, 10.5g/dL versus 13.5g/dL; lactate, 3.5mmol/L versus 1.7mmol/L). The area under the ROC curves for FDP, D-dimer, the ratio of FDP to fibrinogen, the ratio of D-dimer to fibrinogen, hemoglobin and lactate levels were 0.900, 0.882, 0.918, 0.900, 0.815 and 0.765, respectively. CONCLUSION: Coagulation biomarkers, and hemoglobin and lactate levels could be useful to predict the existence of arterial extravasation due to pelvic fracture. The ratio of FDP to fibrinogen and the ratio of D-dimer to fibrinogen were the most accurate markers. Coagulation biomarkers may enable more rapid and specific treatment for pelvic fracture.

Metallo-ß-lactamase-producing Klebsiella pneumoniae infection in a non-hospital environment.

Case: A 92-year-old female resident at a nursing home was transported to the emergency department unconscious, hypotensive, and febrile. Chest X-rays and computed tomography revealed a permeation shadow in the right lung. The patient was diagnosed with sepsis due to pneumonia. At the time of admission, she had not received antibiotics or treatment using medical devices over the past 6 months. Two sets of samples were taken for blood and sputum cultures, and Klebsiella pneumoniae was isolated from all cultures. The strain was identified as metallo-ß-lactamase-producing K. pneumoniae, and the patient was successfully treated with tazobactam-piperacillin. This case indicates that metallo-ß-lactamase-producing K. pneumoniae infection occurred in a non-hospital environment. Outcome: After tazobactam-piperacillin treatment, the patient was transferred to another hospital. Conclusion: Emergency physicians should be aware of multidrug-resistant bacterial infection even in a non-hospital setting.

Genuine splenic artery aneurysm rupture treated by N-butyl cyanoacrylate and metallic coils under resuscitative endovascular balloon occlusion of the aorta.

Case: A 66 year-old woman who presented with sudden lower abdominal pain was transferred to our emergency room. Vital signs were stable on arrival at the hospital, but immediately became unstable. Systolic/diastolic blood pressure and heart rate were 66/33 mmHg and 70 b.p.m., respectively. Computed tomography scanning showed splenic artery aneurysm rupture and extravasation. The patient was treated non-operatively and definitively by endovascular therapy comprising resuscitative endovascular occlusion of the aorta for hemodynamic control, N-butyl cyanoacrylate, and metallic coils as an embolization material. Outcome: On admission day 3, she was enrolled in another department and admission day 54, she was discharged. Conclusion: Although resuscitative endovascular occlusion of the aorta and N-butyl cyanoacrylate is known to be effective, the use of resuscitative endovascular occlusion of the aorta with transcatheter arterial embolization and N-butyl cyanoacrylate for non-traumatic bleeding has not previously been reported. By combining and adapting these devices, their applications in endovascular management may be increased.

Massive hemothorax due to inferior phrenic artery injury after blunt trauma.

Injury to the inferior phrenic artery after blunt trauma is an extremely rare event, and it may occur under unanticipated conditions. This case report describes an injury to the left inferior phrenic artery caused by blunt trauma, which was complicated by massive hemothorax, and treated with transcatheter arterial embolization (TAE). An 81 year-old female hit by a car while walking at the traffic intersection was transferred to the emergency department, computed tomography scanning revealed active extravasations of the contrast medium within the retrocrural space and from branches of the internal iliac artery. The patient underwent repeated angiography, and active extravasation of contrast medium was observed between the retrocrural space and the right pleural space originating from the left inferior phrenic artery. The injured left inferior phrenic artery was successfully embolized with N-butyl cyanoacrylate, resulting in stabilization of the patient's clinical condition. Inferior phrenic artery injury should be recognized as a rare phenomenon and causative factor for hemothorax. TAE represents a safe and effective treatment for this complication and obviates the need for a thoracotomy.