Critically ill patients require huge resources because of dysfunction of several vital organs. The heterogeneity and complexity of the ICU patient have generated interest in systems that would be capable of assessing the severity of illness with the objective of predicting the outcomes, comparing the quality of care, and stratifying patients for clinical trials. Because the ICU mortality rate has been strongly correlated with the number of failing organs and with the degree of organ dysfunction, quantification of organ dysfunction/failure is also important. The advantages of accurate assessment of a patient's risk include the opportunity to give a more accurate prognosis and choose the most appropriate therapy. This review describes three different general severity-of-illness models, including several versions, four single organ failure scoring models, and four multiple organ failure models. As there are several pitfalls related to the interpretation of the numbers supplied by the systems, they should not be used without knowledge of the science of severity scoring. Pertinent use of the tools would make it possible to judge the severity of illness accurately and would be useful for discrimination of critically ill patients, providing optimum therapy, and decreasing the ICU mortality.

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This is the first case report of a pediatric blunt abdominal aortic injury in Japan. A 12-year-old boy was crushed between 2 personal watercrafts on a lake. Initially, an emergency medical service vehicle transported him to a neighboring hospital. Plain computed tomography (CT) scan revealed retroperitoneal hematoma, and the doctors suspected a major vascular injury. Two hours after the event, the patient was transferred to our hospital by air rescue. Contrast-enhanced CT scan performed on arrival revealed an abdominal aortic injury. Aortagraphy revealed a pseudoaneurysm formation and extravasation from the aortic bifurcation. We inserted an occlusion balloon catheter into the infrarenal aorta. We inflated the balloon and blocked the infrarenal aortic blood flow. He was immediately transferred to the operating room. Under blockade of the aortic blood flow, the retroperitoneal cavity was opened. We observed that the posterior wall of the terminal aorta was split longitudinally by approximately 2 cm. This laceration was repaired using primary sutures. The postoperative course was uneventful. Preoperative occlusion balloon catheter blockade is effective in attenuating hemorrhage from the abdominal aorta; although it is difficult to apply this catheter in a child because of the narrowness of the aorta.

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A 74-year-old man was admitted to the emergency department due to sudden right lateral abdominal pain. On computed tomography (CT), rupture of a hepatocellular carcinoma (HCC) in segment 7 of the liver was observed, and transcatheter arterial chemoembolization (TACE) was subsequently performed because of hemorrhagic shock. The patient recovered from his initial critical condition. Three days later, the patient developed respiratory failure due to acute interstitial pneumonia, but he recovered with artificial respiration and steroid pulse therapy. Twenty days later, the patient developed biliary peritonitis due to necrosis and perforation of the gallbladder, but he again recovered with drainage. A second TACE was performed four months later followed by a third eight months later. Eleven months later,intrahepatic metastasis and peritoneal dissemination were not detected, and right hepatectomy with removal of part of the diaphragma and cholecystectomy was performed. On pathology, a diagnosis of a moderately to poorly differentiated hepatocellular carcinoma was made. The patient was discharged on postoperative day 18 and remains alive 2 years 9 months after surgery without recurrence. Transcatheter arterial embolization (TAE) for initial hemostasis followed by secondary hepatectomy might improve the prognosis of patients with HCC who develop hemorrhagic shock.

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Aneurysmal subarachnoid hemorrhage is one the most common causes of sudden death. We herein report a patient who presented with prehospital cardiopulmonary arrest (CPA) caused by subarachnoid hemorrhage who survived with a good neurological function. A 52-year-old male had a traffic accident, thereafter CPA occurred and cardiopulmonary resuscitation was then immediately performed by a bystander. An ambulance was requested, and advanced cardiopulmonary life support was administered upon arrival and thereafter was continued until reaching the hospital. The return of spontaneous circulation was observed about 23 minutes after the onset of the CPA. On arrival, the patient's consciousness level was E1VTM5. ECG showed an elevation of the ST segments at V₁ to V₅. A brain CT scan revealed a diffuse subarachnoid hemorrhage predominantly in the right hemisphere. Cerebral angiography showed a saccular aneurysm of the right middle cerebral artery. Because ocular deviation disappeared, a prompt light reflex was observed, the patient underwent a craniotomy to perform neck clipping of the aneurysm. The patient was discharged on foot without any neurological deficits. Therefore, immediate CPR by a bystander and intensive care have the potential to improve the survival rate and the functional outcome of subarachnoid hemorrhage patients presenting with prehospital CPA.

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Hypermagnesemia is a rare and often iatrogenic condition caused by the administration of magnesium-containing medications. We report 3 cases of severe hypermagnesemia caused by the long-term administration of magnesium oxide for constipation. The serum magnesium levels of the patients exceeded 15 mg/dl and caused shock and coma. Although the patients were treated with intravenous calcium and conventional or continuous hemodialysis, one of them died. Studies have reported that severe hypermagnesemia caused by the administration of magnesium oxide is less common than that caused by the administration of a single dose of any other magnesium-containing medications, such as magnesium citrate or magnesium sulfate, that contain a larger magnesium load. However, the findings in the present cases suggest that long-term administration of magnesium-containing medications with a lower magnesium load can also be a risk factor for severe hypermagnesemia. Hypermagnesemia is difficult to diagnose because of nonspecific symptoms. In addition, it can be fatal if initial diagnosis and treatment have been delayed. Therefore, close observation with serum magnesium measurements according to need should be performed when magnesium-containing cathartics are prescribed to a patient for a long time.

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An 87-year-old woman was admitted to the emergency department due to disturbance of consciousness. Subsequently, the condition was identified as shock. We diagnosed a right common iliac artery aneurysm (CIAA) rupture with contrast-enhanced abdominal computed tomography, which did not show extravasation of the contrast agent but showed a rugged vessel wall; it also revealed bilateral CIAA. Hemorrhagic shock responded to fluid resuscitation. Further, the patient had risk factors for surgery including advanced age, history of an abdominal surgery, hypertension, and dementia. Therefore, our therapeutic strategy for the right CIAA rupture was to perform endovascular aneurysm repair (EVAR) rather than an abdominal surgery because EVAR is less invasive than open surgery. Preoperative planning of EVAR includes occluding bilateral internal iliac arteries followed by placing a stent graft. The patient's hemodynamics stabilized after surgery, and she returned home without any complications. We therefore suggest that patients who have risk factors for abdominal surgery and in whom hemorrhagic shock responds to fluid resuscitation might benefit from EVAR for an iliac artery rupture.

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We report a case of airway obstruction caused by megaesophagus complicated by achalasia. A 77-year-old woman was taken to our hospital because of acute dyspnea. On arrival, her state of consciousness was E3V1M4 according to the Glasgow coma scale, stridor was audible, and paradoxical labored respiration was observed. Vesicular sounds were absent upon auscultation. A blood gas analysis showed severe respiratory acidosis (pH 6.96; PaCO₂, 150 mmHg). An emergency laryngoscopy did not demonstrate an upper airway obstruction as far as the glottis. A computed tomography scan revealed a markedly dilated esophagus (maximal diameter of 82 mm), which had occluded the trachea adjacent to the sternal notch. Tracheal intubation rapidly improved both the patient's respiratory distress and impaired consciousness. After a review of previous medical literature, we identified 37 cases of airway obstruction caused by achalasia and found that in most reports, including the present report, elderly women were affected. Because achalasia develops in all age groups and both sexes, we considered the possible etiology from several perspectives, but the cause remained a mystery. Airway obstruction caused by achalasia should be considered as part of a differential diagnosis of acute dyspnea, especially in elderly women.

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