We conducted a questionnaire survey to investigate problems in the usage of trauma registries at Trauma/Critical Care Centers and Emergency Departments within university hospitals in Japan. Of the 244 facilities, 84 replied via self-administered questionnaire (a response rate of 38%). We collected data regarding the management of existing trauma registries and assessed attitudes towards, expectations of and willingness to participate in the newly established Japan Trauma Data Bank (JTDB). The JTDB is a national trauma registry developed by the Japanese Associations of Acute Medicine and the Surgery of Trauma. Of the 84 responding facilities, 47 had computerized trauma registries but only 9 of the 47 facilities employed personnel for data entry. The work-burden involved in physical data entry and the actual quality of the data stored on registries were reported as major problems. To resolve these issues, it was suggested that centers allocate more personnel, make available more funds, reduce the amount of information requiring data entry, and simplify the data being entered. Sixty-one facilities stated their intention to participate in the JTDB. It was felt that the JTDB would lead to improvement in the quality of trauma care; be helpful in bridging the gap in the quality of trauma care between facilities and regions; enhance the awareness of the role of departmental staff; facilitate the sharing of information with emergency service personnel; be helpful for injury control. In sum, the JTDB would not only be useful for the purposes of medical audit but also would be helpful in alleviating the work-burden of data entry and should lead to an improvement in the quality of data collected. Therefore, it would appear reasonable to recommend that all efforts be made to expand the registry's coverage.

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We describe a case of right internal mammary artery (IMA) perforation as a very rare complication of central venous catheterization (CVC). A 43-year-old woman was hospitalized for anorexia and ascites, and intravenous alimentation was indicated to treat her malnutrition. After failed right jugular vein approach, she complained of chest pain. One hour later when she was in semiconscious state, a right subclavian approach did not allow successful insertion. A later attempt under fluoroscopy revealed collapse of her right lung. A massive right hemothorax was diagnosed by chest computed tomography. When we were consulted 4 hours after the first puncture, she was already deeply comatose due to serious shock. Fluid resuscitation, tracheal intubation and tube thoracostomy were immediately performed. Afterward, we carefully maintained her systolic blood pressure between 80 and 90mmHg with chest tube clamping and declamping, and controlling the infusion rate. Subsequent angiography revealed extravasation of contrast medium from the right IMA, and complete hemostasis was obtained by coil embolization. The patient had no further bleeding and eventually made a full recovery. We should be fully aware of the potentially lethal hazards of CVC. This is apparently the first report of IMA damage during CVC in Japan.

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A case of severe acute pancreatitis and acute hepatic failure after valproate overdose combined with acetylsalicylate is described. A 53-year-old man was admitted to our emergency room because of consciousness disturbance. Blood analysis showed lactic acidosis and hyperammonemia. Six hours after admission, serum concentrations of valproate and acetylsalicilate were 1, 555μg/ml and 114μg/ml, respectively. The therapeutic concentration of valproate is from 50 to 100μg/ml. The patient was treated with direct hemoperfusion using a charcoal column over two hours and with hemodiafiltration for four hours, starting 16 hours after admission. Although concentration of valproate was decreased to 237μg/ml after the treatment with blood purifications, severe acute pancreatitis and acute hepatic failure progressively developed, resulting in death on the 3rd day of hospitalization. Overdose of valproate and actylsalicylate has been demonstrated to have an adverse effect on the mitochondrial function. Moreover, it has been shown that both drugs compete binding to serum albumin and consequently the free valproate level is increased in sera. Early hemodialysis and hemoperfusion may be effective in the management of valproate overdose with coma, respiratory depression and hemodynamic instability.

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We report a case of traumatic massive airway hemorrhage which was successfully treated by intubatiog the intact side main bronchus with a single-lumen tracheal tube. A 16-year-old man was injured in a traffic accident and sent to our hospital. After being admitted, he showed a massive airway hemorrhage, mainly from the left bronchus. We inserted a single-lumen tracheal tube into the intact right bronchus with the intention that the swollen cuff may protect blood flowing in from the contralateral damaged bronchus. The trial was successful and the patient showed a dramatic improvement in his blood gas analysis and X-ray. As the hemorrhage subsided the next day, we moved the tube up to the trachea. Rapid absorption of the blood congested in the damaged lung took place and no hypoxia, due to shunt, atelectasis, or other complications, ensued. Massive airway hemorrhage is a difficult condition and still carries a high mortality rate, though some complicated rescuing attempts, with a double-lumen tube or some special tubes, have been made. We support that intubation of intact-side bronchus with a single-lumen tracheal tube is a quick, easy, handy, and effective way when massive airway hemorrhage occurs in the hemiside bronchus.

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A comatose 24-year-old man with blurred vision had metabolic acidosis (pH 6.831), CO₂ tension of 13.6mmHg, bicarbonate of 2.2mEq/l, and an anion gap of 21.7mEq/l. He was intubated and treated with sodium bicarbonate intravenously, then referred to our emergency department. The urine alcohol screening test by methanol detection tube was positive and serum/urine analysis revealed a serum methanol level of 2.7mg/ml and formic acid level of 969.0μg/ml. He underwent 4-hour hemodialysis twice. Non-enhanced CT showed hypodensity bilaterally in the putamen. On hospital day 2, MRI revealed hyperintense lesions in and around the putamen and subcortical white matter on T2-weighted and fluid attenuated inversion recovery (FLAIR). Axial diffusion-weighted (DW) images showed hyperintense lesions in the bilateral putamen and subcortical white matter, indicating cytotoxic edema. Also, short TI inversion recovery (STIR) showed bilateral optic nerve edema. On hospital day 26, MRI showed putaminal necrosis and improvement of optic nerve edema. He gradually became alert from hospital day 4. He could see distant finger movement but still had impaired vision after 1 year. He survived due to our new and rapid way of identifying methanol poisoning by detection tube, and quick hemodialysis. CT/MR image findings also revealed lesions in the basal ganglia, especially the putamen, and cortex.

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A 54-year-old civil engineer received the weight of the tight quarter excavator for a moment at 11am on June 1, 2002, while operating the one. The handlebar then struck him on the epigastrium. He was transported in an ambulance after about an hour after injury to our hospital, complaining of abdominal severe pain. He had epigastric pain with a golf ball-like swelling in the epigastric region. He had a remarkable tenderness with rebound pain on his upper abdomen without obvious external injury. Upper abdominal enhanced computed tomography visualized massive hematoma in bursa omentalis with extravasation of contrast media in lesser curvature of stomach, and moderate volume of a hemoperitoneum in liver border. He developed in hemorrhagic shock on examination at the emergency room. We suspected that he had intraabdominal hemorrhage possibly due to injury of visceral artery around the stomach, and an emergency laparotomy was performed for the purpose of hemostasis. At laparotomy, active bleeding from transected right gastric artery where it originated from the common hepatic artery with a large mass of hematoma in bursa omentalis was doubly ligated proximally and distally. The patient recovered uneventful and was discharged on the 14th day after injury.

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