The prevention and control of hospital infection is an important issue for the management of the hospital care. Recently, many of the multiple-drug resistant strains of bacteria for example of MRSA (methicillin resistant Staphylococcus aureus), MDRP (multiple-drug resistant Pseudomonas aeruginosa), and VER (vancomycin-resistant Enterococci) are infected in immunocompromised patients hospitalized in the emergency units. Drug resistant bacterial infection though to be a serious problem in the immunocompromised patients because the empiric therapy of antibiotics may be ineffective. The most important issue against the drug resistant bacterial infection is the prevention of the infection. MRSA is the most common pathogen for nosocomial infection, but recently community acquired MRSA is cultured from the patients outside the hospital. MDRP and VRE are still rare isolated from the patients in the hospitals in Japan. However, theses pathogen can eradicated limited antimicrobial agents, the prevention of the transmissions of MDRP or VRE are necessary for the infection control. We experienced the outbreaks of MDRP and VRE infection occurred in our hospital before a few years. We took measures to the prevention of the drug resistant bacterial hospital infection. We reviewed the effective countermeasures to the prevention and infection control of drug resistant bacterial infection based on the our experiences of the outbreak.

View full abstract

A population-based study was conducted to clarify the relationship between the pre-hospital findings and the outcome in trauma victims. The number of patients carried to hospitals by ambulance per year (April 2006 through March 2007) in the Hiroshima District (population approx. 1,340,000) was 14,091. The patients were classified as; group A (positive initial assessment in the physiological domain), group B (no findings on initial assessment, but positive findings after a rapid trauma survey in the anatomic domain), group C (positive findings only on scene size-up in the mechanistic domain), and group D (no findings for Load & Go). Questionnaires were sent to hospitals asking about the outcome of the victims on 14th day after the injury, and were returned in 12,595 cases (89.4%). Fifty-one victims died within 14 days, and 40 of them were in group A. The number of victims who died, experienced multiple traumas, or both, was 90/355 (25.4%) in group A, 14/216 (6.0%) in group B, 5/357 (1.4 %) in group C, and 2/11,724 (0.02%) in group D. The initial assessment is thus considered to be the most important predictor and a rapid trauma survey is the second most important predictor of the outcome in trauma victims.

View full abstract

A rare case of delayed hypoglossal nerve palsy associated with occipital condyle fracture is reported. A 24-year-old man accidentally fell from his bicycle and sustained a blow to the left temple. He was alert and oriented in the emergency department. On neurological examination, he was able to stick out his tongue. Because of his complaint of headache and neck pain, brain computed tomography (CT) scan and cervical spine radiographs were obtained. Both imaging studies were considered normal, and he was discharged. A week later, however, he returned to our clinic complaining of tongue deviation and persistent neck pain. A CT scan of the craniocervical junction revealed occipital condyle fracture of the right side involving the hypoglossal canal, and the fracture was apparently responsible for the hypoglossal nerve palsy. Since the fracture was considered stable biomechanically, he was treated conservatively with the use of a rigid cervical collar. His neck pain subsided gradually and tongue deviation resolved within 4 months of injury. Occipital condyle fractures are not as rare as had been believed earlier, and may occur even after low-energy trauma. The possibility of occipital condyle fractures should be considered when treating patients with mild head injuries who complain of persistent neck pain, even if their cervical spine series appear normal.

View full abstract

A 20-year-old male was found lying in front of a condominium in the early morning. Judging from his condition, he had fallen from the 4th floor, and he was transported to our hospital. On arrival, he was stupefied and restless. Laboratory tests showed metabolic acidosis and marked hyperglycemia (1520 mg/dL), and his blood pressure was gradually decreasing. Further evaluation showed intra-abdominal bleeding, and fractures of the sacrum and T12 vertebra. Bladder rupture was suspected due to noted hematuria with clots, and an emergency laparotomy was performed. Intra-abdominal inspection revealed bladder rupture and arterial bleeding. After hemostasis and bladder wall repair, retroperitoneal hematoma was enlarged, and angiography was performed after laparotomy. Transcatheter arterial embolization was performed for the left and right lateral sacral arteries and the left obturator artery. The HbA1c was 5.9% and diabetes-related autoantibodies were negative; fulminant type I diabetes was diagnosed. The patient had most likely fallen and injured himself due to impaired consciousness associated with diabetic ketoacidosis. With both conditions, this patient's trauma-related stress probably exacerbated the hyperglycemia. However, even with coexisting fulminant type I diabetes, early volume resuscitation and glycemic control with insulin have no major complications in the course of traumatic injury.

View full abstract

von Recklinghausen's disease is known to frequently be complicated with various diseases, such as brain tumors, bone abnormalities, and the malformation of vessels. We herein describe a case of von Recklinghausen's disease that was complicated with an airway obstruction due to a rupture of cervical pseudoaneurysm. A 48-year-old male, arrived at our hospital with dyspnea and left cervical swelling. On arrival, he was able to talk, but soon thereafter, his dyspnea worsened due to an airway obstruction. We tried intubation, but his oral cavity was filled by submucosal mass lesion, therefore surgical tracheostomy was performed. Cervical dynamic CT showed multiple pseudo aneurysm ruptures, which thus resulted in the formation of a hematoma which displaced the trachea to the right side. After admission, bleeding from the external carotid artery continued, therefore transcatheter arterial embolization (TAE) was performed, and the patient was therefore able to survive. Bleeding from a cervical pseudo aneurysm may lead to sudden airway obstruction, and it can sometimes be fatal, Therefore, when encountering a case presenting with von Recklinghausen's disease and cervical swelling, we should carefully carry out airway management, and perform TAE if indicated.

View full abstract

Even among non-trauma patients, damage control surgery has a wide application. We report on a case of gastrointestinal tract necrosis with disseminated intravascular coagulopathy (DIC) which occurred after the ingestion of a large amount of strong acid and which we treated with damage control surgery. A 70-year-old man was admitted after ingesting about 250ml of 35% hydrochloric acid. 7 hours after ingesting the acid, he exhibited hypotension and coagulopathy. Necrosis of entire stomach and duodenum were observed in an emergency exploratory laparotomy. Total gastrectomy and total pancreas-preserving duodenectomy without reconstruction were conducted. Because perioperative coagulopathy was sustained, vacuum pack closure was immediately performed with gauze packing to prevent retroperitoneal oozing. A second operation, including esophagectomy and pancreatico-choledochojejunostomy, was planned to be performed after coagulopathy had improved in the ICU, but the patient's family refused consent. Accordingly, only depacking and feeding jejunostomy were performed as palliative surgeries once his condition was good enough. The patient expired 28 days after admission due to mediastinitis from residual esophageal necrosis. Damage control surgery can be adequately applied in a non-trauma setting.

View full abstract