An infected chronic expanding haematoma treated with hip disarticulation.

This is a report of an anticoagulated patient with septic shock caused by an infected chronic expanding haematoma (CEH) that required hip disarticulation as a means of definitive surgical source control. As far as we know, we did not find any report of an infected giant CEH in the lower extremity as large as in the present patient.

Incidence, demographics and outcomes of patients with penetrating injury: a Japanese nationwide 10-year retrospective study.

BACKGROUND: Unintentional injury remains the leading cause of death among Japanese people younger than 35 years; however, data are limited on the evaluation of characteristics, long-term mortality trend and mortality risk of patients with penetrating injury in Japan. This prevents the development of effective strategies for trauma care in patients with penetrating injury. METHODS: This retrospective cohort study investigated 313 643 patients registered in the Japan Trauma Data Bank (JTDB) dataset between 1 January 2009 and 31 March 2018. The inclusion criteria comprised patients with penetrating injuries transferred from the injury site by emergency vehicles. Moreover, the patients registered in the JTDB dataset were included in this study regardless of age and sex. Outcomes measured were nationwide trends of characteristics, in-hospital mortality and in-hospital mortality risk among Japanese patients with penetrating injury. The mortality risk was analysed by hospital admission year, age, Injury Severity Score (ISS) and emergency procedures. RESULTS: Overall, 7132 patients were included. Median age significantly increased during the 10-year study periods (from 48 to 54 years, p=0.002). Trends for the mechanism of injury did not change; the leading cause of penetrating injury was stab wounds (SW: 76%-82%). Overall, the in-hospital mortality rate significantly decreased (4.0% to 1.7%, p=0.008). However, no significant improvement was observed in the in-hospital mortality trend in all ISS groups with SW and active bleeding. Patients with active bleeding who underwent urgent transcatheter arterial embolization had significantly lower mortality risk (p=0.043, OR=0.12, 95% CI=0.017 to 0.936). Conversely, the surgical procedure for haemostasis did not improve the mortality risk of patients with SW and active bleeding. CONCLUSION: The severity-adjusted mortality trend in patients with penetrating injuries did not improve. Moreover, patients with active bleeding who underwent urgent surgical procedure for haemostasis had a higher mortality risk.

Abdominal compartment syndrome secondary to a large retroperitoneal hematoma caused by ruptured gastroduodenal artery pseudoaneurysms in a patient with severe acute pancreatitis.

Background: Abdominal compartment syndrome (ACS) is a known complication of severe acute pancreatitis. It is typically secondary to visceral edema and aggressive fluid resuscitation, but rarely caused by a retroperitoneal hematoma due to ruptured visceral pseudoaneurysms. Case Presentation: A 49-year-old man presented in shock with a history of heavy alcohol use and was transferred to the intensive care unit with a diagnosis of severe acute pancreatitis. Computed tomography scan on hospital day 2 revealed a large retroperitoneal hematoma due to ruptured gastroduodenal artery pseudoaneurysms. Despite adequate resuscitation, the patient developed ACS, which required decompressive laparotomy on hospital day 10. Open abdominal management was continued until multiorgan failure resolved. He was eventually discharged to a rehabilitation hospital 3 months after presenting. Conclusion: We report a patient with severe acute pancreatitis who underwent decompressive laparotomy for ACS secondary to a large retroperitoneal hematoma due to ruptured gastroduodenal artery pseudoaneurysms.

Impact of the COVID-19 pandemic on a trauma center of a university hospital in Japan.

BACKGROUND: The Coronavirus disease 2019 pandemic caused the Japanese government to declare a State of Emergency on April 7, 2020. The aim of this study is to provide an overview of the effects of the pandemic on surgical cases at a university hospital trauma center. METHODS: An observational study was performed at a trauma center in a tertiary hospital in Tokyo, Japan. The number of surgeries was compared between two periods: a historical control period (Tuesday April 9 to Monday May 27, 2019) and the period of the Japan State of Emergency due to COVID-19 (Tuesday April 7-Monday May 25, 2020). Information on patient age, gender, and surgical diagnosis, site, and procedure was collected for cases operated on in each period. The number of trauma surgeries was compared between the two periods. Data from the two periods were compared statistically. RESULTS: The total number of surgical cases was 151 in the control period and 83 in the COVID-19 period (including no cases with COVID-19), a decrease of 45.0%. There were significantly more surgeries for patients with hip fractures in the COVID-19 period (9 vs. 19, P < 0.001 by Fisher exact test). CONCLUSIONS: During the State of Emergency in Japan, the number of operations for trauma patients at the trauma center decreased, but surgeries for hip fracture increased.

Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients.

Out-of-hospital cardiac arrest (OHCA) is a growing worldwide public health concern. Previously, Japan experienced poorer outcomes among OHCA patients than in other high-income countries. In the early 1990s, through policy changes, the Japanese government introduced a task-shift model in pre-hospital care. Some medical practices previously provided by physicians exclusively were delegated to non-physicians, including laypeople. Additionally, we initiated a nationwide data collection system for evaluation. We started a nationwide registry of OHCA patients, a paramedic system to provide advanced life-support care, and basic life-support training for laypeople. In the 2000s, the procedures paramedics could provide were expanded, laypeople were allowed to use automated external defibrillators, and the Utstein style was introduced to the national registry. Consequently, pre-hospital advanced care and bystander first-aid increased, registry-based research contributed to evidence-based practices, and-most importantly-outcomes of OHCA patients considerably improved. These Japanese experiences demonstrate that streamlining pre-hospital care, including bystander interventions and standardized data collection, can improve OHCA patient outcomes. Despite this progress, however, there still exist many issues to be addressed in response to the changing and increasing care demands within Japan's aging population.

Prospective evaluation of the "Stop the Bleed" program in Japanese participants.

BACKGROUND: The Stop the Bleed (STB) program was developed to bring military bleeding control techniques into wider use among American civilians. It was introduced in Japan in case of mass casualty events during the Tokyo Olympic/Paralympic Games in 2021, and its effectiveness was prospectively evaluated. METHODS: Japanese physicians certified as STB instructors held bleeding control basic training courses from April to July 2019. Participants' knowledge was assessed using pre-training and post-training tests comprising five questions. One point was awarded for each correct answer, giving a maximum total score of 5. (Q1) What is the most common preventable trauma death?; (Q2) Which actions should be prioritized for bleeding victims?; (Q3) Which patients should be transferred to hospital first?; (Q4) How should a tourniquet be applied?; (Q5) How should pain associated with a tourniquet be managed? RESULTS: The study involved 157 participants (20 physicians/nurses, 82 medical students, 33 emergency services personnel, 22 police officers/security personnel). The mean±SD scores were 2.1±1.1 before training and 3.2±1.0 after training (p<0.01). The respective percentages of correct answers before and after training were 58% and 75% for Q1, 10% and 13% for Q2, 38% and 55% for Q3, 73% and 89% for Q4, and 33% and 91% for Q5. Q2 had the lowest percentage of correct answers and the poorest improvement. DISCUSSION: The STB program improved tourniquet knowledge. However, it was less effective in improving knowledge about which actions to prioritize for bleeding victims. This may be because the participants were well trained in basic life support and therefore expected to immediately commence cardiopulmonary resuscitation for patients in shock. The STB program is valuable in preparing Japanese people for mass casualty events during the Tokyo Olympic/Paralympic Games in 2021. LEVEL OF EVIDENCE: IV. STUDY TYPE: Therapeutic.

Hybrid emergency room system improves timeliness of angioembolization for pelvic fracture.

BACKGROUND: Timely angioembolization (AE) is known to improve outcomes of patients with hemorrhage resulting from pelvic fracture. The hybrid emergency room system (HERS) is a novel trauma resuscitation room equipped with a computed tomography scanner, fluoroscopy equipment, and an operating room setup. We hypothesized that the HERS would improve the timeliness of AE for pelvic fracture. METHODS: A retrospective medical record review of patients who underwent AE for pelvic fracture at our institution from April 2015 to December 2018 was conducted. Patients' demographics, location of AE, Injury Severity Score, Revised Trauma Score, probability of survival by the trauma and injury severity score (TRISS Ps) method, presence of interventional radiologists (IRs) upon patient arrival, time from arrival to AE, and in-hospital mortality were analyzed. These data were compared between patients who underwent AE in the HERS (HERS group) and in the regular angio suite (non-HERS group). RESULTS: Ninety-six patients met the inclusion criteria. The HERS group comprised 24 patients, and the non-HERS group, 72 patients. Interventional radiologists were more frequently present upon patient arrival in the HERS than non-HERS group (IRs, 79% vs. 22%, p < 0.01). The time from arrival to AE was shorter in the HERS than non-HERS group (median [range], 46 [5-75] minutes vs. 103 [2-690] minutes, p < 0.01). There were no differences in the rate of in-hospital mortality (13% vs. 15%, p = 0.52) between the two groups. Survivors in the HERS group had a lower probability of survival by the trauma and injury severity score (median [range], 61% [1%-98%] vs. 93% [1%-99%], p < 0.01) than survivors in the non-HERS group. CONCLUSION: The HERS improved the timeliness of AE for pelvic fracture. More severely injured patients were able to survive in the HERS. The new team building involving the addition of IRs to the traditional trauma resuscitation team will enhance the benefit of the HERS. LEVEL OF EVIDENCE: Therapeutic, level IV.

Emergency trauma laparotomy and/or thoracotomy in the emergency department: risks and benefits.

BACKGROUND: It is not mandatory for Japanese trauma centers to have an operating room (OR) and OR team available 24 hours a day/7 days a week. Therefore, emergency laparotomy/thoracotomy is performed in the emergency department (ED). The present study was conducted to assess the safety of this practice. METHODS: The data were reviewed from 88 patients who underwent emergency trauma laparotomy and/or thoracotomy performed by our acute care surgery group during the period from April 2013 to December 2017. Operation was performed in the ED for 43 of 88 patients (51%, ED group), and in the OR for 45 of 88 patients (49%, OR group). The perioperative outcomes of the two groups were compared. RESULTS: Compared with the OR group, the ED group had a higher Injury Severity Score (30±15 vs. 13±10, p<0.01), greater incidence of blunt trauma (74% (32/43) vs. 36% (16/45), p<0.01), larger volume of red blood cell transfusion (18±18 units vs. 5±10 units, p<0.01), higher incidence of new-onset shock after sedation among patients who received sedation in the ED (59% (17/29) vs. 25% (6/24), p<0.01), and higher in-hospital mortality rate (49% (21/43) vs. 0, p<0.01). All five patients who underwent laparotomy followed by thoracotomy died in the ED; none of these patients underwent preoperative placement of resuscitative endovascular balloon occlusion of the aorta (REBOA). Of the 21 patients in the ED group who died, 17 (81%) died immediately postoperatively; furthermore, 12 of the 22 patients who survived (55%) were not in shock prior to operation. DISCUSSION: Emergency trauma laparotomy and/or thoracotomy outcomes were related to injury severity. The resources for trauma operations in the ED seemed suboptimal. The outcome of trauma operations may be improved by reviewing the protocols for anesthetic care, and by the usage of REBOA rather than aortic cross-clamping. LEVEL OF EVIDENCE: IV.

Performing Trauma Surgery in the Emergency Room Impacts the Timeliness of Surgery.

BACKGROUND: Our institution has emergency rooms (ERs) with an operating room (OR) setup, which enables surgeons to perform thoracotomy and/or laparotomy for trauma patients without transferring patients to the OR. We hypothesized that the ERs with an OR setup improve the timeliness of surgery for trauma patients. MATERIALS AND METHODS: Data were reviewed from trauma patients who underwent emergency surgeries performed by our acute care surgery group from April 2013 to June 2017. Patients' demographics, diagnoses, location of the operation (ER versus regular OR), type of operation, time from admission to operation, and perioperative outcomes including in-hospital mortality were analyzed. These data were compared between patients who underwent surgery in the ER versus the OR. RESULTS: There were 105 trauma patients who met the inclusion criteria. Of these 105 patients, 50 underwent surgery in the ER (47.6%, ER group), whereas 55 underwent surgery in the OR (52.4%, OR group). Compared with the OR group, the ER group had a shorter time from admission to operation (median 43 min [range 3-105 min] versus 109 min [range 15-1340 min], P < 0.04), and higher in-hospital mortality rate (38.2% versus 0%, P < 0.01). CONCLUSIONS: An ER with an OR setup can enable surgery to be started sooner. Compared with the OR group, patients who underwent surgery performed in the ER tended to be in a more serious condition, and were thus likely to have a higher mortality rate. Further study is warranted to determine which patients would benefit best from this approach.

Investigation of optimal position for implantable loop recorders by potential mapping with Reveal DX.

BACKGROUND: Electrode positioning is important for the operation of implantable loop recorders (ILRs). This study aimed to investigate optimal electrode positions for the implantation of ILRs. METHODS: Fifteen male subjects participated in the study and R wave amplitude data were collected from 15 areas in the left anterior chest area, with 4 variations of electrode angles and body positions. RESULTS: The estimated minimum R wave amplitude values were greater than 0.3 mV (manufacturer-recommended value) when electrodes were angled vertically and positioned on the midclavicular line of the third and the forth intercostal spaces or on the left sternal border of the fourth and fifth intercostal space and when angled at 45° to the right on the left sternal border of the third and the forth intercostal space. CONCLUSIONS: Exploring areas around the left sternal border of the fourth intercostal space - where the R wave amplitudes are least affected by body positions - is a reliable method for choosing implantation locations for ILRs.