高エネルギー損傷の結果として生じる治療困難な重度下腿開放骨折(Gustilo type III B, C)に対する皮弁形成術の有用性について検討した。対象症例は2000年4月から2003年10月までの期間において,当救命救急センターにて加療を行った重度下腿開放骨折9例である。男性8例,女性1例で,受傷時平均年齢は32.9歳であった。以上の症例に対して受傷時に積極的デブリドマンと一時的創外固定術を施行し,さらに可能な限り受傷後数日以内に皮弁形成術による軟部組織再建術と確定的骨接合術を施行した。その結果,9例中7例において患肢温存が得られたが,2例は後日切断術を施行した。患肢温存が得られた7例のうち6例は1次骨癒合が獲得され,平均骨癒合期間は5.5か月(3～7か月)であった。骨癒合が遅延した1例に対しては追加骨移植術によって骨癒合が得られた。合併症として骨髄炎を併発した症例は認められなかった。2cm程度の脚短縮が1例に認められたが,10度以上の角状変形と回旋変形を認めた症例はなかった。さらに膝関節可動域および足関節可動域は比較的良好に保たれ,全例受傷1年以内に杖なし歩行が可能となった。重度開放骨折に対する早期皮弁術は非常に有効な手術手技である。
A thirty-year-old male was transferred to our emergency department after being injured in an automobile accident. He was conscious at the time of admission. Chest X-ray revealed fracture of the left first rib and a gradually increasing mediastinal shadow, which suggested injury to the subclavian artery. On the day of injury, the patient exhibited right hemiparesis, without any abnormality on head CT scan. There was no laterality or blood flow reduction on SPECT, and no major vessel occlusions were detected with using TCD. Thoracic CT scan revealed fractures of the 4th and 5th thoracic vertebrae, but no spinal cord injuries were found using MRI. Angiography revealed complete occlusion of the left common carotid artery and collateral circulation. His right hemiparesis gradually improved, and MRI revealed no infarcted lesion in the brain. In this case, blunt thoraco-cervical trauma caused fracture of the first rib, which has lead to injury of the carotid artery and jugular vein. These major vessel injuries led to transient hemiparesis and increasing mediastinal bleeding. Carotid artery injury is a rare complication of traumatic head and neck injury, and common carotid injury caused by thoraco-cervical trauma is extremely rare. Angiography is the gold standard for diagnosis of such vessel injuries, and aggressive examination is recommended for such complicated injuries.
Hemodialysis is the usual recommended treatment for severe lithium intoxication when emergent extracorporeal lithium removal is necessary. Intermittent hemodialysis has been chosen most frequently, however it has disadvantages such as postdialysis rebound elevation in lithium concentration, hemodynamic instability, tendency to develop hypovolemia and deteriolate renal function. On the other hand continuous hemodiafiltration (CHDF) offers an advantage of slow sustained removal of lithium without the adverse effects of conventional hemodialysis. The following is a report of a case of severe chronic lithium intoxication successfully treated with CHDF. A 69-year old woman, who had been diagnosed with manic-depressive psychosis 18 years previously, was transferred to our ICU because of unconsciousness during lithium maintenance therapy (lithium carbonate 800mg/day). On arrival her consciousness level was Japan Coma Scale 100 and the pulse rate was 30beats/min. Since she had a past history of cardiac failure, we conducted CHDF to accelerate lithium elimination. CHDF was continued for 64 hours and thereafter her condition improved uneventfully.
A 44-year-old female was transferred to our hospital in a semi-comatose state, suffering from shock (Glasgow coma scale E1V2M5, blood pressure 74/34mmHg). The blood examination demonstrated hypoglycemia (25mg/dl) and extremely severe anemia (1.5g/dl). Immediate glucose infusion and a slow transfusion achieved a dramatic improvement in the blood pressure and a clear consciousness, but the heart failure symptoms slightly deteriorated. A further examination of anemia and her history of schizophrenia revealed that her dietary habits and ignorance of her disease had resulted in severe anemia. After an infusion of diuretic and iron, the heart failure and anemia symptoms improved and she was thereafter moved to the psychiatric ward. To the best of our knowledge, this is the first report of an adult patient who survived after presenting with a hemoglobin level below 2g/dl and thereafter survived.
A 33-year-old man was admitted to our emergency room with tachycardia and hypotension. Diffuse swelling, extensive blistering were noted in the body region extending from the left thigh to the left scrotum. Laboratory data revealed severe metabolic acidosis with an elevated anion gap and high lactate level, leukocytosis and renal dysfunction. Bacteriological examination of the exudate obtained from the blisters revealed numerous Gram-positive cocci. Although computed tomography revealed only swelling of the left thigh and scrotum, MRI, which was performed when the patient was clinically stable at the previous hospital, clearly suggested extensive myofascitis of the left thigh. An emergency debridement of the infected wounds was carried out, and intraoperative histopathological diagnosis guided the area of debridment. The resected tissues from the left thigh and scrotum revealed widespread necrosis and large numbers of Gram-positive cocci, which were identified as Group A β-hemolytic streptococci. In this case report, we show that MRI and intraoperative histopathological examination are more effective than computed tomography for the early diagnosis of TSLS.
The subject was a 21-year-old male who fell from a motorcycle, and injured his epigastrium on the handlebar. He visited a doctor in his neighborhood, and was given blood tests, abdominal x-rays, and an abdominal CT. He was diagnosed with abdominal bruising and kept under observation. On the 2nd day after the injury, he started to experience tarry stools; on the 13th day, he started to experience dizziness particularly when he stood up. Therefore he visited our hospital. During the examination, he exhibited significant anemia. Gastroscopy revealed that there was a submucosal tumor in the anterior and posterior walls of stomach. In addition, in the mucous of the tumor, punctuate petechiae were observed. According to these results, the patient was diagnosed as having gastric intramural hematoma caused by blunt injury and anemia due to bleeding from the mucous rupture. Iron dosing gradually improved anemia, and further bleeding from the mucous rupture was prevented by fasting. With gastroscopy conducted on the 53rd day after the injury, the gastric hematoma was confirmed to have disappeared. Gastric intramural hematoma seems to require treatment for delayed complications. It is important to keep patients under observation anticipating that they might develop delayed complications. The details of the examination for this case are given for future reference.