BACKGROUND: Recently, the occurrence of a higher brain dysfunction after brain injury has been socially noticed and epidemiological investigations have thus been performed. However, most of these previous investigations tended to be based on populations in a chronic stage after brain trauma. We hypothesized that some patients with a higher brain dysfunction were socially in extreme distress after being discharged from our hospital due to a lack of any follow-up treatment. We investigated this problem to identify possible problems in diagnosing and follow-up for a higher brain dysfunction after blunt traumatic brain injury at a tertiary emergency center.
METHODS: A questionnaire survey was performed for 204 blunt trauma patients who had been admitted during the period from January 2000 thorough December 2003. Clinical examinations were performed for patients suspected of having a higher brain dysfunction based on this questionnaire survey.
RESULTS: Three patients had been already diagnosed to have a higher brain dysfunction while other 3 patients were newly diagnosed in this investigation. The newly diagnosed patients discharged from departments other than the neurosurgery department. Computed tomography (CT) was performed in 82% patients (65 patients) to diagnose major brain injury or bone fracture. No magnetic resonance image was performed to detect any minor brain injury in alert patients.
CONCLUSIONS: Overlooking the occurrence of a higher brain dysfunction may result from an insufficient recognition of higher brain dysfunction and an insufficient sensitivity of the present diagnostic methods available for minor brain injury. An increased awareness regarding the potential of a higher brain dysfunction existing in such patients is therefore needed by the entire medical staff and the general public.

View full abstract

BACKGROUND: Nonoperative management (NOM) of hepatic injuries caused by blunt trauma in hemodynamically stable patients is widely accepted, but the feasibility of NOM for severe hepatic injuries has not been fully evaluated.
METHODS: Among all patients with blunt severe hepatic injury (type IIIb) admitted to Saiseikai Kanagawa-ken Hospital and Keio University Hospital from 1988 to 2004, those who had been hemodynamically stable after fluid resuscitation at the emergency department were initially managed nonoperatively. We reviewed demographic, physiological, and laboratory data; computed tomography (CT) findings; 80-day cumulative laparotomy rate; and complications. The anatomical severity of the hepatic injuries was evaluated based on the CT findings, such as hepatic vein injuries and area lacerated according to the Couinaud liver segment. In patients who underwent surgery after admission, the surgical indications and operative findings were reviewed.
RESULTS: Overall, 34 consecutive patients were enrolled in this study. Five patients underwent surgery, and all of their surgical indications were attributable to liver-related complications after injury. The indication for surgery was hemodynamic instability in 3 patients with hepatic vein injures in the early phase (<15 hours after ER arrival) and intra-abdominal septic complications in 2 patients in the late phase (hospital days 14 and 64). The cumulative 80-day laparotomy rate in the early phase was significantly higher (p<0.0001) in the patients suspected of having hepatic vein injury, and in the late phase it was higher (p=0.002) in those with injuries in 4 or more segments of hepatic injuries.
CONCLUSIONS: For the successful NOM of blunt hepatic injury type IIIb in patients who are hemodynamically stable after fluid resuscitation, a strong suspicion of concurrent hepatic vein injury is critical in the early phase, and laceration in 4 or more segments should be noted in the late phase.

View full abstract

A 52-year-old man was admitted 1 hour after he had ingested 300 ml of a strong alkaline developing solution consisting mainly of potassium carbonate. On admission, he complained of abdominal pain and nausea. The gastrointestinal endoscopy revealed hemorrhagic erosion and mucosal necrosis of the esophagus, stomach and duodenum. Ventricular fibrillation occurred transiently attributable to hyperkalemia due to absorption of potassium. On the third hospital day, abdominal compartment syndrome (ACS) caused by intestinal edema developed. Decompression laparotomy was performed, and 170 cm of completely necrosed small intestine was removed. The second look operation was performed on the 13th hospital day. Since multiple necrosis and perforations were observed over the stomach, total gastrectomy and reconstruction were performed. Although the patient subsequently underwent multi-disciplinary treatment, necrosis of the entire intestinal tract occurred, and the patient died on the 26th hosipital day. There is only a report of poisoning by consumption of potassium carbonate. In our case, necrosis to the serous membrane of the stomach and small intestine occurred in a short period of time. Consumption of a large volume of strong alkali requires appropriate management while paying attention to not only the upper digestive tract, but also small intestine, including the occurrence of ACS.

View full abstract

Perforation of the gastrointestinal tract due to toothpick accidentally swallowed is rare, and its preoperative diagnosis is difficult because patients rarely relate a history of swallowing a toothpick and most toothpicks are not radiopaque. We report a case in which this condition was diagnosed preoperatively. A 73-year-old man arrived at the hospital with a high fever (39°C) and swelling of the scrotum and buttocks. He stated that one week earlier he had accidentally swallowed an artificial tooth while eating. Laboratory data revealed acute inflammation although x-ray films ultrasonographic images and computed tomographic images of the abdomen revealed no signs of a foreign body or perforation of the gastrointestinal tract. Retention of gas (indicated by an image of air) was found in the area from the rectum to the front of the pubis and along the edge of the bladder. A digital rectal examination revealed a toothpick about 6cm long, which was extracted manually. We diagnosed that the toothpick had perforated the rectum, so he underwent an emergency operation with a diagnosed of a perforated the rectum caused by the toothpick. Infection has been well managed by repeated washing and rinsing.

View full abstract

We report a case in which ingestion of surface active agents caused numerous small intestinal ulcers and perforations. The 45-year-old male patient, who attempted suicide by ingesting large amounts of surface active agents, was admitted to our hospital with acute drug poisoning. The patient presented with melena and complained of continuous pain in the right lower abdomen during his clinical course. Various examinations including endoscopy and abdominal angiography suggested that the haemorrhage originated from ulcers of the small intestine. Treatment was therefore started with continuous arterial infusion of vasopressin, which temporarily controlled the bleeding. Symptoms of peritonitis then appeared and melena recurred. We suspected perforative peritonitis caused by small intestinal ulcers and performed emergency ileocecal resection, leaving 1.6m of jejunum. Melena persisted after the operation, seeming to originate from ulcers of the residual small intestine. However, examinations detected no clear source of bleeding, The patient's symptoms improved with conservative treatment and he was discharged from the hospital 55 days after surgery. When a patient suffers from intoxication caused by surface active agents, in most cases toxic symptoms improve with excretion through the intestine. However, as in the present case, serious conditions triggered by factors such as intestinal stasis as a result of obstruction can occur, and such patients should be very carefully monitored and observed.

View full abstract

We report the case of a patient who suffered cardiac arrest due to poisoning by the contents of a fire extinguisher. A 68-year-old man who was hospitalized for schizophrenia sprayed the contents of a fire extinguisher into his mouth. He was immediately transferred to our emergency room. On arrival, he was in shock and soon went into cardiopulmonary arrest due to hyperkalemia (Serum K⁺ 10.3 mEq/l). He underwent successful cardiopulmonary resuscitation. The hyperkalemia was subsequently resolved by 15 hours of continuous hemodiafiltration conducted in our intensive care unit. The cardiopulmonary arrest was considered to be caused by hyperkalemia that in turn was caused by absorption of the fire extinguisher contents. Generally, fire extinguishers are rarely a cause of poisoning. We present a case that demonstrates the importance of careful observation when the contents of a fire extinguisher are ingested or inhaled.

View full abstract