Hidden Inferior Vena Cava Injury: A Case of Missed Diagnosis after Preoperative CT and Laparotomy.

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

Clostridium perfringens-induced liver abscess with severe haemolysis.

Clostridium perfringens is notorious for causing skin and soft tissue infections and food poisoning. Rarely, C. perfringens infections are associated with severe haemolysis, with a mortality rate of >80%. A previously healthy man in his 70s who presented with fever as his chief symptom was promptly admitted to a regional core hospital. Over the next 3 hours, shock and multiple organ failure ensued, leading to referral to our hospital for intensive care. We suspected a liver abscess caused by C. perfringens infection with haemolysis, findings of severe haemolysis and a liver mass with gas production that appeared within a few hours. Though surgical drainage was contemplated, low blood pressure resulted in death within 3 hours of arrival at our hospital. The next day, a blood culture confirmed C. perfringens, proving the diagnosis. Improving patient outcomes requires increased awareness of the disease and early detection.

The need to suspect tension gastrothorax as a cause of obstructive shock in trauma care: A case report.

INTRODUCTION: Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy. PRESENTATION OF CASE: A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures. DISCUSSION: Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest. CONCLUSION: When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

Spinal cord injury without radiological abnormality due to a fall while using an abdominal roller: A report of two cases.

Background: In recent years, various home-use health devices have gained popularity. The abdominal roller is one of these. Spinal cord injury without radiological abnormality is known to occur even with relatively minor injuries, but there are few reports of such injuries caused by a roller. Case Presentation: Two cases of spinal cord injuries caused by a roller are reported. In both cases, injuries occurred during the standing rollout by a patient in an inebriated state, and the patients were rushed to an emergency department. Conclusion: Because the use of abdominal rollers may result in extremely serious disabilities, it is necessary to emphasize the appropriate use of such equipment.

Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for adult convulsive status epilepticus: a multicentre non-inferiority randomised control trial.

OBJECTIVE: Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is crucial. Although fosphenytoin (FPHT) is recommended as a second-line treatment, levetiracetam (LEV) reportedly has similar efficacy, but higher safety. Therefore, we herein compared LEV with FPHT in adult SE. METHODS: We initiated a multicentre randomised control trial in emergency departments with adult patients with convulsive SE. Diazepam was initially administered, followed intravenously by FPHT at 22.5 mg/kg or LEV at 1000-3000 mg. The primary outcome was assigned as the seizure cessation rate within 30 min of the administration of the study drug. RESULTS: A total of 176 adult patients with SE were enrolled (82 FPHT and 94 LEV), and 3 were excluded from the full analysis set. Seizure cessation rates within 30 min were 83.8% (67/80) in the FPHT group and 89.2% (83/93) in the LEV group. The difference in these rates was 5.5% (95% CI -4.7 to 15.7, p=0.29). The non-inferiority of LEV to FPHT was confirmed with p<0.001 by the Farrington-Manning test. No significant differences were observed in the seizure recurrence rate or intubation rate within 24 hours. Serious adverse events developed in three patients in the FPHT group and none in the LEV group (p=0.061). CONCLUSION: The efficacy of LEV was similar to that of FPHT for adult SE following the administration of diazepam. LEV may be recommended as a second-line treatment for SE along with phenytoin/FPHT. TRIAL REGISTRATION NUMBER: jRCTs031190160.

Necrotizing Soft-Tissue Infection of the Trunk Resulting From Wound Caused by a Centipede: A Case Report.

BACKGROUND Centipede envenomation is usually mild, but a review of the existing literature revealed a more serious course in a small proportion of patients. In fact, necrotizing soft-tissue infections have been reported following centipede stings in a small number of cases and require early diagnosis and treatment because of a high mortality rate. CASE REPORT A 78-year-old man was stung by a centipede on the left abdomen. Treatment with antimicrobial agents was started due to cellulitis, but extensive erythema developed from the left chest to the left buttock. Six days after being stung, he visited our hospital. Necrotizing soft-tissue infection was diagnosed and treated immediately with antibiotics and debridement on the left side of the abdomen and chest. Group A Streptococcus was detected in the fascia. The wound was left partially open and washed daily, resulting in gradual improvement of the wound condition. On hospitalization day 8, the open wound was able to be closed. Antimicrobial therapy was completed on hospitalization day 16. The patient showed good progress. CONCLUSIONS Centipede stings are not rare in tropical and subtropical regions, and most occurrences of centipede envenomation cause only local symptoms. However, we believe that even wounds caused by centipedes should be monitored, given the possibility of subsequent severe infection, as in the present case. In addition, the causative organisms identified in the present patient with necrotizing soft-tissue infection following a centipede sting were commensal bacteria of the skin. Future research is thus needed to clarify the relationship between these causative organisms and centipedes.

Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for status epilepticus: study protocol for a multicenter non-inferiority designed randomized control trial.

BACKGROUND: Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is important. Phenytoin and fosphenytoin, the prodrug of phenytoin with less severe adverse effects, have been recommended as second-line treatments. However, fosphenytoin causes severe adverse events, such as hypotension and arrhythmia. Levetiracetam reportedly has similar efficacy and higher safety for SE; however, evidence to support its use for adult SE is lacking. In the present study, a non-inferiority designed multicenter randomized controlled trial (RCT) is being conducted to compare levetiracetam with fosphenytoin after diazepam as a second-line treatment for SE. METHODS: This multicenter, prospective, and open-label RCT is conducted in emergency departments. Between December 23, 2019, and March 31, 2023, 176 patients with convulsive SE transported to an emergency room will be randomized into a fosphenytoin group and levetiracetam group at a ratio of 1:1. The definition of SE is "continuous seizures longer than 5 min or discrete seizures longer than 2 min with intervening consciousness disturbance." In both groups, diazepam is initially administered at 1-20 mg, followed by intravenous fosphenytoin at 22.5 mg/kg or intravenous levetiracetam at 1000-3000 mg. The primary outcome is the seizure cessation rate within 30 min. Seizure recurrence within 24 h, severe adverse events, and intubation rate within 24 h are secondary outcomes. DISCUSSION: The present study was approved and conducted as an initiative study of the Japanese Association for Acute Medicine. If non-inferiority is identified, the society will pursue an application for the national health insurance coverage of levetiracetam for SE via a public knowledge-based application. TRIAL REGISTRATION: Japan Registry of Clinical Trials jRCTs031190160 . Registered on December 13, 2019.

Predictors of fatal outcome after severe necrotizing fasciitis: Retrospective analysis in a tertiary hospital for 20 years.

BACKGROUND: Prognostic factors for fatal outcomes of patients with necrotizing fasciitis remain unclear. METHODS: We retrospectively analyzed data of patients with necrotizing fasciitis from January 1998 to July 2019 using our hospital's medical database. Clinical characteristics of patients who died during hospitalization or had been discharged were evaluated. Sex, age, body mass index, smoking history, alcohol use, comorbidities (diabetes mellitus, arteriosclerosis obliterans, heart disease, obstructive arteriosclerosis, dialysis, cancer, skin disease, steroid use history), shock vital, physical findings, Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, sepsis, disseminated intravascular coagulation, fascial administration, tracheal intubation, and surgical treatment (dismemberment and/or debridement) were compared between the survivor (group S) and nonsurvivor (group N) groups. RESULTS: Fifty-five patients with necrotizing fasciitis were included (40 patients in group S and 15 patients in group N). Serum creatine was a significant prognostic factor (odds ratio [OR], 3.03; 95% confidence interval [CI], 0.15-0.75; P = 0.0078), with a cutoff value of 1.56 mg/dL. Moreover, the estimated glomerular filtration rate was a significant prognostic factor (OR, 1.06; 95% CI, 1.02-1.10, P = 0.000548), with a cutoff value of 20.6 mL/min. CONCLUSION: Renal dysfunction is a significant prognostic factor for fatal outcomes of patients with necrotizing fasciitis. LEVEL OF EVIDENCE: Level IV, Case series.

The utility of resuscitative endovascular balloon occlusion of the aorta for temporary hemostasis after extensive bilateral lower extremity injuries: A case report.

A 75-year-old pedestrian was struck by a truck and in shock with both lower extremities significantly deformed, with injuries extending proximally to the inguinal region and degloving injuries. Resuscitative endovascular balloon occlusion of the aorta was performed to achieve temporary hemostasis and the patient became hemodynamically stable. Following stabilization, both lower extremities were amputated. Resuscitative endovascular balloon occlusion of the aorta may be effective to achieve temporary hemostasis in patients with extensive injuries of the lower extremities, especially with extension to the inguinal region which precludes use of a tourniquet.

Contamination of healthcare workers' hands with bacterial spores.

Clostridium species and Bacillus spp. are spore-forming bacteria that cause hospital infections. The spores from these bacteria are transmitted from patient to patient via healthcare workers' hands. Although alcohol-based hand rubbing is an important hand hygiene practice, it is ineffective against bacterial spores. Therefore, healthcare workers should wash their hands with soap when they are contaminated with spores. However, the extent of health care worker hand contamination remains unclear. The aim of this study is to determine the level of bacterial spore contamination on healthcare workers' hands. The hands of 71 healthcare workers were evaluated for bacterial spore contamination. Spores attached to subject's hands were quantitatively examined after 9 working hours. The relationship between bacterial spore contamination and hand hygiene behaviors was also analyzed. Bacterial spores were detected on the hands of 54 subjects (76.1%). The mean number of spores detected was 468.3 CFU/hand (maximum: 3300 CFU/hand). Thirty-seven (52.1%) and 36 (50.7%) subjects were contaminated with Bacillus subtilis and Bacillus cereus, respectively. Nineteen subjects (26.8%) were contaminated with both Bacillus species. Clostridium difficile was detected on only one subject's hands. There was a significant negative correlation between the hand contamination level and the frequency of handwashing (r = -0.44, P < 0.01) and a significant positive correlation between the hand contamination level and the elapsed time since last handwashing (r = 0.34, P < 0.01). Healthcare workers' hands may be frequently contaminated with bacterial spores due to insufficient handwashing during daily patient care.

Predictability of the Call Triage Protocol to Detect if Dispatchers Should Activate Community First Responders.

INTRODUCTION: Shortening response time to an emergency call leads to the success of resuscitation by chest compression and defibrillation. However, response by ambulance or fire truck is not fast enough for resuscitation in Japan. In rural areas, response times can be more than 10 minutes. One possible way to shorten the response time is to establish a system of first responders (eg, police officers or firefighters) who are trained appropriately to perform resuscitation. Another possible way is to use a system of Community First Responders (CFRs) who are trained neighbors. At present, there are no call triage protocols to decide if dispatchers should activate CFRs. OBJECTIVE: The aim of this study was to determine the predictability to detect if dispatchers should activate CFRs. METHODS: Two CFR call triage protocols (CFR protocol Ver.0 and Ver.1) were established. The predictability of CFR protocols was examined by comparing the paramedic field reports. From the results of sensitivity of CFR protocol, the numbers of annual CFR activations were calculated. All data were collected, prospectively, for four months from October 1, 2012 through January 31, 2013. RESULTS: The ROC-AUC values appear slightly higher in CFR protocol Ver.1 (0.857; 95% CI, 79.8-91.7) than in CFR protocol Ver.0 (0.847; 95% CI, 79.0-90.3). The number of annual CFR activations is higher in CFR protocol Ver.0 (7.47) than in CFR protocol Ver.1 (5.45). CONCLUSION: Two call triage protocols have almost the same predictability as the Medical Priority Dispatch System (MPDS). The study indicates that CFR protocol Ver.1 is better than CFR protocol Ver.0 because of the higher predictability and low number of activations. Also, it indicates that CFRs who are not medical professionals can respond to a patient with cardiac arrest.

Development of a first-responder dispatch system using a smartphone.

We constructed a prototype community first responder (CFR) dispatch system. The system sends incident information, including a map, to the chosen CFR's mobile phone. We tested it in a simulation of 30 out-of-hospital cardiac arrest incidents which had occurred in the town of Motegi during the previous year. Thirty off-duty firefighters acted as CFRs and were sent to the same locations. The mean response time (from the CFR receiving dispatch information to arrival at the scene) was 3 min 37s faster than the actual response time in the corresponding historical control, i.e. the response time was reduced by 36% (P < 0.01). The median travel distance of the CFRs was 3.4 km and there was a positive correlation between response time and travel distance. The study showed that interactive communication between dispatcher and CFR was important for effective operation and that CFRs could reach an OHCA patient before the Emergency Medical Service arrives.

Introduction of the community first responder system into Japan: is that possible?

BACKGROUND: To improve out-of-hospital cardiac arrest (OHCA) survival rates in Japan, implementation of a community first responder (CFR) system is considered one of the most effective emergency medical service options. We investigated the possibility of introducing a CFR system in Japan. METHODS: Cross-sectional surveys were given to 1,350 residents over the age of 18 who were selected from resident registration lists in Tochigi prefecture. Residents were questioned whether they would agree to have a CFR system in their community and whether they would participate as a responder. Positive attitudes about the cross-sectional study led us to conduct pilot CFR trials. Trials were conducted in rural areas of Tochigi prefecture by local EMS personnel. We were able to discuss and develop CFR introduction guidelines for Japanese communities using the results of the individual surveys, pilot trials, and other countries' guidelines. Finally, our CFR system, which referred to developed CFR introduction guidelines, was introduced into Ishikawa prefecture's Shioya town (population of 710). RESULTS: A total of 92.5% of Tochigi residents either strongly agreed or agreed to have a CFR system in their community, and 16.7% of Tochigi's residents chose to participate. The two CFR introduction prerequisites were identified as: (1) an information delivery system for CFR and (2) budget preparation. CFR introduction guidelines were developed, and a CFR system was introduced in Shioya town on 4 November 2012 with 32 participants. On 1 January 2013, a CFR responded for the first time, and the CFR system worked efficiently. CONCLUSIONS: By providing information about the CFR system to the community and preparing several infrastructural elements, it was possible to introduce and operate a successful CFR system in Japan.

Takotsubo cardiomyopathy as a delayed complication with a herbicide containing glufosinate ammonium in a suicide attempt: a case report.

Background. Glufosinate ammonium has a famous delayed complication as respiratory failure, however, delayed cardiogenic complication is not well known. Objectives. The aim of this study is to report a takotsubo cardiomyopathy as a delayed complication of glufosinate ammonium for suicide attempt. Case Report. A 75-year-old woman ingested about 90 mL of Basta, herbicide for suicide attempt at arousal during sleep. She came to our hospital at twelve hours after ingesting. She was admitted to our hospital for fear of delayed respiratory failure. Actually, she felt down to respiratory failure, needing a ventilator with intubation at 20 hours after ingesting. Procedure around respiratory management had smoothly done with no delay. Her vital status had been stable, however, she felt down to circulatory failure and diagnosed as Takotsubo cardiomyopathy at about 41 hours after ingestion. There was no trigger activities or events to evoke mental and physical stresses. Conclusion. We could successfully manage takotsubo cardiomyopathy resulted in circulatory failure in a patient with glufosinate poisoning for suicide attempt. Takotsubo cardiomyopathy should be taken into consideration if circulatory failure is observed for unexplained reasons.

Successful management of aortic thrombi resulting in spinal cord infarction in a patient with antiphospholipid antibody syndrome and acute cholecystitis.

A 74-year-old man with coronary artery disease was suffering from acute nonobstructive cholecystitis and was admitted to a nearby hospital. Dual antiplatelet (aspirin and ticlopidine) therapy was discontinued before preparation for surgical resection of the gall bladder. During his time in hospital he was aware of lumbar pain and weakness in both legs. He was transferred to our hospital for further evaluation and therapy. Diffuse intra-aortic thrombi were revealed by computed tomography with contrast media, and magnetic resonance imaging showed spinal cord infarction. However, computed tomography scans of the descending aorta obtained 4 months before admission exhibited no signs of atherosclerotic plaques or intra-aortic thrombi. Laboratory data suggest that antiphospholipid antibody syndrome might have caused these acute multiple intra-arterial thrombi. By restarting dual antiplatelet therapy and increasing the dose of heparin (from 10,000 IU/day to 15,000 IU/day) we successfully managed the patient's clinical condition and symptoms. It is important to understand that stopping antiplatelet therapy may rapidly grow thrombi in patients with a hypercoagulative state.

Combining continuous endotoxin apheresis and continuous hemodiafiltration in the treatment of patients with septic multiple organ dysfunction syndrome.

When septic multiple organ dysfunction syndrome (MODS) occurs as a result of endotoxemia, diverse chemical mediators are excessively produced, and the patient becomes seriously ill. Under such circumstances, it is difficult to improve the patient's condition by endotoxin apheresis alone and hemodiafiltration should be carried out to remove excessive chemical mediators. Series-parallel treatment combining continuous endotoxin apheresis and hemodiafiltration is recommended for patients with septic MODS.

Effectiveness of combining plasma exchange and continuous hemodiafiltration in patients with postoperative liver failure.

Nine patients with postoperative liver failure were treated with plasma exchange (PE) or PE and continuous hemodiafiltration (CHDF), and various biochemical parameters were determined before and after treatment. Although citrate levels increased significantly after treatment compared with pretreatment levels in both the PE group and the PE + CHDF group (P < 0.0001 and P < 0.0001, respectively), the percentage of the increase in citrate levels was significantly higher in the PE group than in the PE + CHDF group (P = 0.0051). Total bilirubin (T-Bil) levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0001, respectively). There were no significant differences in T-Bil levels between the two groups (P = 0.5181). There were no significant differences in interleukin (IL)-6 levels before and after treatment in both the PE and PE + CHDF groups (P = 0.1281 and P = 0.2273, respectively). IL-18 levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0002, respectively), but there were no significant differences in the removal rate of IL-18 in both the PE and PE + CHDF groups (P = 0.8749). These results indicate that combining PE and CHDF in a series-parallel circuit is an effective modality for suppressing the elevation of blood citrate levels. This finding may have important implications for the development of an effective treatment for patients with postoperative liver failure.

The series-parallel circuit in the treatment of fulminant hepatitis.

We developed a series-parallel treatment method for combined plasma exchange (PE) and continuous hemodiafiltration (CHDF) therapy in fulminant hepatitis. We then compared total serum bilirubin, citrate, and cytokine levels obtained by the new methods to those obtained with treatment by the single and reverse-parallel PE methods. Ten adult patients with fulminant hepatitis consented to participate. Plasma exchange was conducted 25 times by the single method (PE only), 16 times by the reverse-parallel method, and 37 times by the series-parallel method. The percentage of total bilirubin removed was highest with the single method followed in order by that with the series-parallel and reverse-parallel methods; the differences were significant. The percentage increase in citrate level was highest with the single method, followed in order by that with the series-parallel and the reverse-parallel methods; these differences were also significant. There was no significant difference in serum interleukin (IL)-6 levels after PE, by the single or the reverse-parallel methods. However, the IL-6 level decreased significantly following PE by the series-parallel method. The serum IL-18 level decreased significantly following PE by each of the three methods. Thus, removal of excess bilirubin, citrate, and cytokines by the series-parallel method, a simple maneuver with excellent removal rates, was considered effective.

IL-15 levels in patients with acute hepatic failure.

Interleukin (IL)-15, an inhibitor of tumor necrosis factor (TNF)-alpha, causes liver injury in mice. We determined levels of IL-15, IL-6, and IL-18 by enzyme-linked immunosorbent assays in 20 patients with acute hepatic failure and examined relationship between these proinflammatory cytokines and IL-15. A significant correlation was observed between the levels of IL-18 and IL-15 (p = 0.0118). IL-15 levels in the nonsurvivors were significantly higher than those in the survivors (p = 0.0357). Our results suggest that IL-15 overexpression may cause liver injury in human.