An analysis of patients with acute aortic dissection who were transported by physician-staffed helicopter.

PURPOSE: The present study aimed to determine whether or not patients with acute aortic dissection (AAD) treated by the staff of a doctor helicopter (DH) service while being transported from the scene or for interhospital transportation obtained a favorable outcome. METHODS: We retrospectively investigated all patients with AAD who were transported by DH between January 2015 and December 2019 using the registry data of the DH control room of our hospital. RESULTS: One hundred five cases were enrolled in the present study. All patients were transported within 24 h from the onset. Male patients accounted for 55.2% of the study population, the average age was 71 years and the rate of Stanford A AAD was 51.4%. Regarding transportation, 61.6% of the patients underwent interhospital transportation, and 42.8% were transported to our hospital. All patients underwent drip infusion during transportation and 81.9% of the patients received drugs (e.g., depressors, pain killers and/or antiemetics). Two patients underwent tracheal intubation due to unconsciousness and profound shock with restless state, respectively. The systolic blood pressure after transportation to hospital was significantly higher in comparison to before transportation. No patients suffered cardiac arrest or showed a deterioration of vital signs. All patients were safely transported to the destination. CONCLUSION: The present study suggests the safety of using a Dr. Heli to transport AAD patients from the scene and for interhospital transportation, even after the onset.

A comparison of physician-staffed helicopters and ground ambulances transport for the outcome of severe thoracic trauma patients.

PURPOSE: We retrospectively investigated prognostic factors for severe thoracic trauma patients evacuated by a physician-staffed helicopter emergency medical service (HEMS) and ground ambulance using the Japan Trauma Data Bank (JTDB). METHODS: This study was a retrospective analysis of the JTDB database. The study period was from January 2004 to May 2019. The subjects were divided into two groups, according to the type of transportation: the Heli group included cases transported by the HEMS, while the Ambulance group included cases transported by ground ambulance. RESULTS: During the investigation period, a total of 57,872 patients were enrolled as subjects, including 7238 in the Heli group and 50,634 in the Ambulance group. The average age, male ratio, average injury severity score (ISS), average revised trauma score (RTS) and survival ratio were significantly greater in the Heli group than in the Ambulance group. After performing a propensity score-matched analysis, there were no statistical differences concerning the age, sex, ISS, RTS between the two groups. However, the survival ratio in the Heli group remained greater than that in the Ambulance group. When variables that showed statistical significance in the univariate analysis were included in a multivariate analysis, the RTS, transport by the HEMS, age, ISS and female gender were identified as significant predictors of a survival outcome. The HEMS was significantly associated with an increased survival ratio (odds ratio: 1.69; 95% confidence interval: 1.51-1.88) compared with a ground ambulance. CONCLUSION: The present study showed that transport by the HEMS improved the survival rate compared to that by a ground ambulance for patients with severe thoracic trauma.

Experience Using a Forehead Continuous Deep Temperature Monitoring System During Air Evacuation.

OBJECTIVE: The present study describes the utility of a forehead continuous deep temperature monitoring system by the staff members of a doctor helicopter (DH). METHODS: A questionnaire survey was performed for all flight doctors who had used this system during transportation by the DH to assess its merits and demerits. RESULTS: The major benefits of this system were its easy usability, disposable nature, low labor cost, continuous demonstration of the deep temperature in a prehospital setting, and low invasiveness. However, drawbacks of this system include its cost; need for a power supply; need for a few minutes for calibration to obtain stable results of temperature, making it impossible to verify the effects of intervention for body temperature during a short flight; and lack of a detachable measuring pad for the forehead when a patient has an injury on the face or head and hyperhidrosis. In addition, the system's attached cables may hamper medical interventions. CONCLUSION: We reported the experience of DH staff using a forehead continuous deep temperature monitoring system in the prehospital setting. Further studies will be required to determine the indications for using such a system in the prehospital setting.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy.

BACKGROUND: The specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents. CASE PRESENTATION: A 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions. CONCLUSION: This is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Clinical Investigation of Burn Patients Transported by Helicopter Based on the Japan Trauma Data Bank.

OBJECTIVE: We retrospectively investigated the actual conditions of burn patients evacuated by helicopter in comparison to those evacuated by ground ambulance using the Japan Trauma Data Bank. METHODS: This study was a retrospective analysis of the data recorded in the Japan Trauma Data Bank between January 2004 and May 2019. After propensity score matching for the method of transportation, the survival rate was compared between the 2 groups. RESULTS: During the investigation period, there were 4,627 burn patients (helicopter group, n = 276; ambulance group, n = 4,351). After propensity score matching, there were no significant differences between the 2 groups in any of the assessed variables, and the survival rate did not differ to a statistically significant extent. CONCLUSION: After propensity score matching, the survival rate of the helicopter group did not appear to be superior to the ambulance group. Further prospective studies are needed to explore the proper indications for air transportation of burn patients, which could potentially improve outcomes.

Prognostic Factors in Trauma Patients Transported by Physician-Staffed Helicopter in Japan: An Investigation Based on the Japan Trauma Data Bank.

OBJECTIVE: We retrospectively investigated prognostic factors for patients evacuated by the physician-staffed helicopter emergency medical service using the Japan Trauma Data Bank. METHODS: The study period was from January 2004 to May 2019. The subjects were divided into 2 groups according to the outcome: the survival group and the fatal group. RESULTS: A total of 19,370 patients were enrolled as subjects. There were 17,080 patients in the survival group and 2,290 in the fatal group. In a multivariate analysis of factors that showed statistical significance in a univariate analysis, the Revised Trauma Score, age, Injury Severity Score, Maximum Abbreviated Injury Scale (MAX-AIS) for the upper extremity (negative), year of helicopter dispatch, Japan Coma Scale, MAX-AIS for the head, MAX-AIS for the abdomen/pelvis, and MAX-AIS for the spine were identified as significant predictors of a fatal outcome . CONCLUSION: This is the first report to investigate the prognostic factors of patients evacuated by helicopter emergency medical service using the Japan Trauma Data Bank. The results suggest that physiological abnormality, age, traumatic anatomic abnormality (other than upper extremity abnormality), and year of helicopter dispatch may be prognostic factors.

Convulsion Treated by a Physician-Staffed Helicopter.

OBJECTIVE: There have been no reports focusing on patients with convulsion treated by a doctor helicopter (DH). We herein report the results of a retrospective analysis investigating the changes in patients' vital signs and clinical manifestations during transportation and the outcomes of treating convulsive patients using a government-funded medical DH. METHODS: We retrospectively investigated all of the patients with convulsion who were transported by the DH between January 2013 and December 2018. RESULTS: A total of 118 cases were enrolled in the present study. The average age was 32 years old, and most were men. Fifty cases showed remaining convulsion when the staff of the DH made contact with the subject. All subjects obtained a survival outcome. Regarding anticonvulsants administered, diazepam was the most frequently used followed by midazolam. The frequency of convulsion after transportation was significantly lower than that before transportation. The Glasgow Coma Scale and peripheral capillary oxygen saturation after transportation to a hospital were higher than before transportation. The heart rate after transportation to a hospital was lower than before transportation. CONCLUSION: The present study indicated the usefulness of a physician-staffed helicopter for treating convulsive patients at the scene.

A patient with clear consciousness even with a glucose level of 5 mg/dL (0.2 mmol/L).

A 74-year-old man noted dysarthria and right hemiparesis. His history included a gastric ulcer 2 years previously, and he had gradually lost 10 kg over a 2-year period due to appetite loss. He daily consumed 120 mg of alcohol. Upon arrival, he had clear consciousness and stable vital signs. He was malnourished. Neurologic findings included a positive finding of Barre sign in the right hand and dysarthria. A venous blood gas analysis demonstrated the following: pH 7.059; PCO2, 21.5 mm Hg; PO2, 59.1 mm Hg; HCO(3-), 5.8 mmol/L; base excess, -22.7 mmol/L; lactate,17 mmol/L; and glucose, 4 mg/dL. After the administration of an infusion of thiamine and glucose, his abnormal neurologic findings subsided completely. Head magnetic resonance image (MRI; diffusion weighted image) disclosed 3 spotty, high-intensity signals in the brain. The main results of biochemical analyses of the blood collected on arrival were as follows: hemoglobin, 5.5 g/dL; glucose, 5 mg/dL; aspartate aminotransferase, 89 IU/L. He was admitted for further examination and was diagnosed as having alcoholic ketoacidosis with hypoglycemic encephalopathy and anemia due to colon cancer.

Vacuum phenomenon.

This article describes the theory of the formation of the vacuum phenomenon (VP), the detection of the VP, the different medical causes, the different locations of the presentation of the VP, and the differential diagnoses. In the human body, the cavitation effect is recognized on radiological studies; it is called the VP. The mechanism responsible for the formation of the VP is as follows: if an enclosed tissue space is allowed to expand as a rebound phenomenon after an external impact, the volume within the enclosed space will increase. In the setting of expanding volume, the pressure within the space will decrease. The solubility of the gas in the enclosed space will decrease as the pressure of the space decreases. Decreased solubility allows a gas to leave a solution. Clinically, the pathologies associated with the VP have been reported to mainly include the normal joint motion, degeneration of the intervertebral discs or joints, and trauma. The frequent use of CT for trauma patients and the high spatial resolution of CT images might produce the greatest number of chances to detect the VP in trauma patients. The VP is observed at locations that experience a traumatic impact; thus, an analysis of the VP may be useful for elucidating the mechanism of an injury. When the VP is located in the abdomen, it is important to include perforation of the digestive tract in the differential diagnosis. The presence of the VP in trauma patients does not itself influence the final outcome.

Management of a Mass Casualty Event Caused by Electrocution Using Doctor Helicopters.

OBJECTIVE: This is the first report to show the use of doctor helicopters in a mass casualty event induced by electrocution. METHODS: We performed a narrative review. RESULTS: Two children obtained electrocution burns by breaking an electric fence. Five adults also received electrocution burns. Emergency medical technicians at the scene requested additional dispatch of an ambulance and the doctor helicopter. Two adult men with cardiopulmonary arrest were transported by 2 ambulances to a nearby hospital. One adult woman was in a restless confusional state, intubated, and transferred to another hospital using the doctor helicopter. One boy, who was initially in a coma, and his mother were transferred to our hospital by 1 ambulance. Another boy, who had finger amputation, was transferred to the other hospital by another doctor helicopter. A remaining elderly woman was transported to the other local hospital by ambulance. All the victims, except the 2 fathers who fell into cardiac arrest, survived. CONCLUSION: Early confirmation of the safety of the scene, early establishment of command and control, early request for dispatch of other parties and the doctor Helicopter, appropriate triage, appropriate treatment at the scene, selecting appropriate medical facilities, and dispersion transportation were crucial.

A case of the vacuum phenomenon as a mechanism of gas production in the abdominal wall.

A 40-year-old man experienced a collision with a car while driving a motorcycle in which the car was in the opposite lane and made a right turn. The patient was thrown approximately 10 m from the point of collision and, as he exhibited a consciousness disturbance, was transferred to our department. He had a score of 13 on the Glasgow Coma Scale with sinus tachycardia on arrival. He showed guarding of the abdomen. A pan scan disclosed traumatic subarachnoid hemorrhage, intraventricular hemorrhage, fractures of the atlas, thoracic spine, sternum and left femur, and gas in the abdomen located just in front of the stomach. As the gas in the abdomen was initially judged to be free air, the patient underwent emergency laparotomy. However, no signs of perforation or injury were detected throughout the entire digestive tract. The accumulation of minute gas (vacuum phenomenon) occurs as traumatic impact. As representative mimics of free air were not observed during surgery in the present case, we believe that the traumatic impact to the patient's abdomen as a result of the collision caused the accumulation of gas in the abdominal wall due to vacuum phenomenon. Physicians should be aware of this clinical entity to accurately recognize the mechanism of gas formation in patients showing negative laparotomy findings for gas in the abdomen. This unique case adds additional information regarding the documented etiologies of mimics of pneumoperitoneum.

A patient with refractory shock induced by several factors, including obstruction because of a posterior mediastinal hematoma.

A 44-year-old man who drove a motorcycle experienced a collision with the side of another motorcycle. Because he had sustained a high-energy injury to the spinal cord, he was transferred to our hospital. His circulation was unstable, and received tracheal intubation in addition to thoracostomy for the hemothorax. Whole-body computed tomography (CT) revealed multiple fractures, right hemopneumothorax with pulmonary contusion, and minor liver injury. After infusing 5000 mL of lactated Ringer's solution and 10 units of blood, his circulation remained unstable. On a repeat CT examination, the left atrium was found to be compressed by a posterior mediastinal hematoma induced by the fracture of the thoracic spine, and a diagnosis of shock induced by multiple factors, including hemorrhagic, neurogenic, and obstructive mechanisms, was made. After obtaining stable circulation and respirations, internal fixation of the extremities and extubation were performed on the 12th hospital day. Chest CT performed on the 27th day showed the disappearance of compression of the left atrium by the hematoma.

Significance of the vacuum phenomenon in patients with trauma evaluated by whole-body computed tomography.

BACKGROUND: Severely traumatized patients undergo whole-body computed tomography (WCT) to detect lethal anatomical injuries. When checking the images, we have sometimes recognized minute gas (the vacuum phenomenon [VP]) near the traumatized lesions. Accordingly, we investigated the significance of the VP in patients with trauma. BASIC PROCEDURES: From April to October 2013, a medical record review was retrospectively performed for all patients with trauma. The exclusion criteria included an age more than 60 years, patients who did not receive the WCT, scan and those in cardiopulmonary arrest on arrival. The subjects were divided into 2 groups: a VP group (n=19), which included patients who had the VP, and a control group (n=49). MAIN FINDINGS: There were no significant differences between the 2 groups with regard to age, the mechanism of injury, or the survival rate. In contrast, the ratio of women, the Injury Severity Score, and the duration of hospitalization in the VP group were significantly higher than those in the control group. The greatest number of the VP was located at or near rib fractures, followed by joint spaces that experienced a traumatic impact. PRINCIPAL CONCLUSION: This study demonstrated that the VP tended to be observed most often in severely traumatized female cases. The VP is observed at locations that experience a traumatic impact, so an analysis of the VP may be useful to elucidate the mechanism of injuries. The presence of traumatic VP itself does not influence the final outcome.

Hospital disaster response using business impact analysis.

INTRODUCTION: The catastrophic Great East Japan Earthquake in 2011 created a crisis in a university-affiliated hospital by disrupting the water supply for 10 days. In response, this study was conducted to analyze water use and prioritize water consumption in each department of the hospital by applying a business impact analysis (BIA). Identifying the minimum amount of water necessary for continuing operations during a disaster was an additional goal. PROBLEM: Water is essential for many hospital operations and disaster-ready policies must be in place for the safety and continued care of patients. METHODS: A team of doctors, nurses, and office workers in the hospital devised a BIA questionnaire to examine all operations using water. The questionnaire included department name, operation name, suggested substitutes for water, and the estimated daily amount of water consumption. Operations were placed in one of three ranks (S, A, or B) depending on the impact on patients and the need for operational continuity. Recovery time objective (RTO), which is equivalent to the maximum tolerable period of disruption, was determined. Furthermore, the actual use of water and the efficiency of substitute methods, practiced during the water-disrupted periods, were verified in each operation. RESULTS: There were 24 activities using water in eight departments, and the estimated water consumption in the hospital was 326 (SD = 17) m³ per day: 64 (SD = 3) m³ for S (20%), 167 (SD = 8) m³ for A (51%), and 95 (SD = 5) m³ for B operations (29%). During the disruption, the hospital had about 520 m³ of available water. When the RTO was set to four days, the amount of water available would have been 130 m³ per day. During the crisis, 81% of the substitute methods were used for the S and A operations. CONCLUSION: This is the first study to identify and prioritize hospital operations necessary for the efficient continuation of medical treatment during suspension of the water supply by applying a BIA. Understanding the priority of operations and the minimum daily water requirement for each operation is important for a hospital in the event of an unexpected adverse situation, such as a major disaster.

Introduction of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture in Japan.

OBJECTIVE: To analyze the operating situation of a physician-staffed helicopter emergency medical service in eastern Shizuoka prefecture. METHODS: A retrospective analysis was performed using the conveyance records reported by staff members of the physician-staffed helicopter. A comparison between 2007 (n = 619) and 2012 (n = 678) was performed. RESULTS: There were no significant differences between the 2 groups with regard to the sex, ratio of cardiopulmonary arrest, and survival ratio. In contrast, the duration from the request of dispatch to arrival at the hospital in 2007 was significantly longer than that in 2012 (53.7 vs 48.2 minutes, P < 0.0001). The average age in 2007 was significantly younger than in 2012 (55.7 vs 59.4 years, P < 0.01). The ratio of trauma case in the 2012 was higher than that in 2007 (47 vs 37%, P < 0.001). The ratio of severe cases in 2007 was higher than in 2012 (45 vs 39%, P < 0.05). CONCLUSION: Japan is an aging society. In eastern Shizuoka prefecture, the increase in the number of trauma and minor injury cases may have increased due to the emphasis on the importance of early medical intervention by the fire department.

Survey of trauma patients injured by falling or flying objects in Japan based on the Japan Trauma Data Bank.

PURPOSE: We retrospectively investigated patients injured by falling/flying objects using the Japan Trauma Data Bank (JTDB). METHODS: The study collected information of the JTEB from January 2004 to May 2019. The subjects were divided into two groups: the unexpected accident (UA) group included cases in which the patient was injured by an unexpected accident; the labor accident (LA) group included cases in which the patient was injured at work. RESULTS: A total of 1997 patients were enrolled as subjects (UA group, n = 383; LA group, n = 1134). In both groups, head injuries were the most frequent type of injury, followed by chest injuries. The median head abbreviated injury scale of the UA group was significantly higher than that of the LA group. In the UA group, the percentage of female patients, average age, and average TRISS value were significantly greater in comparison to the LA group. The frequency of emergency operations in the UA group was significantly lower in comparison to the LA group. The frequency of head injuries in the UA group was significantly greater than that in the LA group. The frequencies of upper extremity and lower extremity injuries in the UA group were significantly lower than those in the LA group. CONCLUSION: This is the first report to analyze trauma patients injured by falling/flying objects using the JTDB. Public health and emergency providers can use this information to anticipate the health-care needs after falling/flying object injuries.

Damage Control Management for Thoracic Trauma with Cardiac Arrest Complicated by Emphysematous Gastritis and Cystitis.

A 78-year-old man was found unconscious after sliding from a rock. His history included hypertension, atrial fibrillation and cerebral infarction requiring warfarin. On arrival, he received six units of blood type O transfusion and vitamin K in an emergency room (ER) due to hemorrhagic shock. His systolic blood pressure temporarily increased to 100 mmHg, and he underwent traumatic pan scan revealing occipital fracture, cerebral contusion, and cervical and multiple left rib fractures with left-dominant bilateral hemothorax. He re-entered a shock state after the examination and underwent transfusion again, but he then entered cardiac arrest. He underwent damage control surgery in the ER and obtained spontaneous circulation. The postoperative course was eventful, but he eventually obtained a survival outcome. Damage control surgery may be beneficial, even in cases of severe thoracic blunt trauma; however, postoperative infections may cause severe problems.