The Tokyo Fire Department revised the defibrillation protocol in 2017, and three years have passed since then, so the effectiveness of the protocol was verified. The effectiveness before and after the revision was compared for 261 cases of cardiopulmonary arrest, by place of occurrence. The protocol revision reduced on-site activity time and hospital arrival time and increased the PCPS attachment rate. Outcomes improved for occurrence in homes and public areas. Revisions to the defibrillation protocol in 2017 contributed to the improved prognosis of cardiopulmonary arrest in the initial waveform.

A man in his 20s was found with his head covered with a plastic bag connected to a helium tank. On admission, his Glasgow Coma Scale score was 10 and a blood gas test showed marked lactic acidosis. The acidosis was improved on the next day, after the ventilator management with sedatives administration. However, generalized convulsion appeared, and 12 days of ventilator management with sedatives and anticonvulsants were required until the convulsion disappeared. Helium gas is not toxic in itself, but inhalation of high concentration can cause hypoxemia, which may cause severe complications including hypoxic encephalopathy and cerebral gas embolism.

The case was 60s male. 10 months prior to the visit, the patient underwent laparoscopic excision of a urachal cyst and had the bladder dome resected and sutured. The patient presented to our emergency department with lower abdominal pain after holding urine for a prolonged period and experiencing pain during urination. Abdominal CT revealed fluid collection around the bladder, and bladder contrast imaging showed leakage of the contrast agent from the bladder dome to outside of the bladder. Therefore, the patient was diagnosed with spontaneous bladder rupture and received antibiotic treatment, followed by laparoscopic bladder repair. Postoperative bladder contrast imaging confirmed that there was no leakage of contrast agent outside the bladder, and the patient was discharged. In this report, we describe a case of spontaneous bladder rupture and discuss the relevant literature.

Syncope is one of the most frequent symptoms in emergency setting. Emergency physician must rule out cardiogenic syncope. A female in her 40’s visited the ER due to transient loss of consciousness. Her electrocardiogram showed a Brugada-pattern with specific ST-elevation. However, her history was atypical as the syncope caused by Brugada syndrome. Her syncope was considered drug-induced since she used isosorbide sulfate spray and had dizziness before the syncope. The diagnosis of syncope is challenging because symptoms disappear when patients arrive. Even in the presence of a Brugada-pattern ECG, a detailed history taking should be conducted for the appropriate disposition.

A 12-year-old boy was injured in a soccer game. He had spontaneous pain in the epigastrium, but no rebound tenderness. Contrast-enhanced computed tomography (CT) showed only duodenal edematous wall thickening and a small amount of ascites in the rectovesical pouch. CT confirmed 14 hours later a new retroperitoneal emphysema, and 23 hours later, increased ascites. Emergency surgery was performed. A perforation was found in the duodenum. If duodenal perforation cannot be diagnosed by CT images in the early stage of injury, it is necessary to strictly manage with repeated follow-up CT so as not to miss the timing of surgery.

A 66-year-old woman had been treated with two doses of antitoxin 4 years previously for a snake bite. Recently, she was bitten again by a pit viper on her right hand and was treated with two doses of antitoxin. Four days later, fever, swollen and tender lymph nodes, and erythema of the whole body developed. She was diagnosed with serum sickness and was treated with steroids and antihistamines. Her symptoms gradually improved without sequelae. Even if no serum sickness occurred after a previous administration of antitoxin, it is important to explain the risk of serum sickness when administering antitoxin again.