We retrospectively analyzed 254 patients to determine the clinical strategy and indications for urgent thoracotomy in cases of blunt chest trauma (Chest AIS score ≥ 3). One hundred fifty-five (61%) of the 254 patients had multiple trauma injuries with other system injury of AIS score ≥ 3. Twenty-four patients (9.4%) required thoracotomy. Nineteen of the 24 patients showed more than one aspect of the “lethal triad” of metabolic acidosis, hypothermia, and coagulopathy, and 5 of the 24 patients showed all three aspects before surgery. Chest tube output of 14 patients who underwent thoracotomy for hemorrhage was less than the traditional amount used as an indication for urgent thoracotomy. Regarding thoracotomy, early-decision making is required for blunt chest trauma patients because of the multiple trauma and critical conditions. The traditional use of high chest tube output as an indicator for thoracotomy may not be applicable to patients with blunt chest trauma.

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The practice of emergency medicine in Japan has been unique in that emergency doctors are mostly engaged in critical care medicine and traumatology at emergency medical service centers. However, with the recent increase in the number of emergency patients, some hospitals have adopted US-style emergency medicine, where emergency physicians take care of all patients presenting to the emergency department regardless of the severity of the injury or illness. In this study, we report the status of implementation of US-style emergency medicine in accredited training institutions for Fellowship of the Japanese Association for Acute Medicine (JAAM). Questionnaires were sent in November, 2007 to 408 accredited training institutions, and valid responses obtained from 248 facilities were analyzed (88%). US-style emergency medicine was provided in 150 facilities (60% of 248 facilities), either in full time (24 hours a day, seven days each week; 82 facilities) or in part time (less than 24 hours a day; 68 facilities). Among these 150 US-style facilities, mode values for number of hospital beds, annual number of emergency patients, and annual number of patients transported by ambulances were 501-750, 10,001-20,000, and 2,001-4,000, respectively. Mode values for number of emergency doctors and for number of emergency physicians were both 1-3. In 139 out of the 150 facilities (93%), first year post-graduates rotate in US-style emergency medicine either totally (74 facilities) or partially (65 facilities). Sixty-eight facilities provide a residency training program, and another 36 institutions plan to build it up. US-style emergency medicine operates in some accredited training institutions for Fellowship of the JAAM; however, its staffing is inadequate. The national strategy to provide emergency doctors/physicians is seemingly essential.

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Cardiac arrest occurred in an 18-year-old male because of a blow inflicted by an ice hockey puck on the exposed neck area between the helmet and neck guard. He was transported to our emergency medical center with cardiopulmonary arrest and given 1 mg of epinephrine, and then heartbeat was restored. A CT scan revealed subarachnoid hemorrhage (SAH) and magnetic resonance imaging revealed bleeding around the brain stem, and his pupils were 8 mm and fixed. He was admitted to the ICU, and hypothermic therapy was performed for three days, but a CT scan on the fifth hospital day revealed brain hypoxia. On the seventh hospital day, he was transferred to another hospital and he died on the fourteenth day. An autopsy was not performed. Autopsy results of similar cases have been reported, and death in those cases was attributed to dissection or rupture of the vertebral or internal carotid artery leading to SAH and brainstem herniation.
We speculated that the cause of death in our case was similar. Body protection is important for amateur sports players, and we conclude that protectors should be improved to avoid such accidents.

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A 29-year-old woman was admitted to our hospital in an unconscious state. She presented with somnolentia and subcutaneous hemorrhage on the face, breast, arms, and legs. Laboratory examination revealed severe anemia and abnormal blood coagulation. Whole-body computed tomography revealed subdural hematoma and intra-abdominal bleeding. Blood was transfused and fresh frozen plasma and vitamin K were administered to treat the anemia and coagulopathy. Burr hole drainage was performed on the second day after the abnormal blood coagulation had improved. The patient was kept under observation due to the intra-abdominal bleeding for abdominal symptoms. The patient's mother informed us that a coumarin anticoagulant rodenticide was found in her room. The patient was subsequently diagnosed as suffering from intoxication induced by the abuse of a coumarin anticoagulant rodenticide. We then continued administering vitamin K, and the patient was discharged from our hospital on the 12th day after admission. Since the patient was unwilling to reveal her history, her condition could not be immediately diagnosed. We recognized the importance of patient history and vital data, including her lifestyle, in the diagnosis. Therefore, intoxication due to coumarin anticoagulant rodenticides should be considered when a patient presents with blood coagulation disorders or bleeding tendency.

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We present a case of hepatic ischemia due to the tamponade effect of a hepatic subcapslar hematoma, which was treated by transcatheter arterial embolization (TAE). Sudden cardiac arrest occurred in a 60-year-old woman at a sports meeting and bystander cardiopulmonary resuscitation (CPR) was performed immediately. She regained a spontaneous circulation by the defibrillation, and was transferred to our emergency department. She was diagnosed with acute myocardial infarction (AMI) by coronary angiography (CAG), and percutaneous coronary intervention (PCI) was performed. After she was taken to ICU, her circulation was unstable and anemia proceeded. Two days after her admission, an abdominal computed tomography (CT) showed a subcapsular and intraparenchymal hematoma in the right lobe of the liver and intraparenchymal hematoma in the left lobe. The right lobe was not enhanced equally in a contrast media study because of the intraparenchymal hypertension due to subcapsular hematoma. We diagnosed this case as liver compartment syndrome. Her serum transaminase increased dramatically compared to that on arrival, so hepatic ischemia obviously existed at that time. TAE was performed and her circulation became stable. Though it is said that the surgical decompression is required in a case of liver compartment syndrome when any signs of hepatic ischemia are present, we successfully managed this case non-operatively.

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We herein report the case of a 39-year-old male who presented with fulminant hepatic failure following exertional heatstroke induced after running 8 km. His temperature was 40.9°C. Acute hepatic failure occurred 3 days later and the patient thereafter fell into a hepatic coma, with a prothronbin level of 20%, aspartate aminotransferase (AST) of 3,330 IU/l, and alanine aminotransferase (ALT) of 5,880 IU/l, hepaplastin test of 20%, arterial ketone body ratio (AKBR) 0.69, and NH₃ 155μg/dl on day 4. We performed plasma exchange (PE), followed by continuous hemodiafiltration (CHDF). The patient thereafter completely recovered while receiving conservative treatment. Severe hepatic failure due to exertional heatstroke typically occurs 3 days after onset and it tends to recover under conservative treatment. An early detailed evaluation of the liver is considered to be essential for the successful clinical management of patients presenting with exertional heatstroke.

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We report a case of traumatic choledochal stenosis successfully treated with percutaneous transhepatic biliary endoprosthesis. A 19-year-old man received a hard blow to his abdomen by an iron bar while catching a fly ball during a baseball game. Approximately ten days after the accident, he was admitted to our hospital because of anorexia and xanthochromic changes in his urine. On admission, impaired hepatic function and jaundice (T.Bil 13.3mg/dl) were observed. Abdominal CT showed dilatation from the intrahepatic bile duct to the superior bile duct and obstruction of common bile duct. Based upon his age and clinical course, the patient was diagnosed as having delayed traumatic choledochal stenosis. Percutaneous transhepatic cholangiodrainage (PTCD) was performed via a 7Fr. tube through the right intrahepatic bile duct. Subsequently, his jaundice improved, but the PTCD tube extubated itself spontaneously, following which another 7 Fr. PTCD tube was inserted through the left intrahepatic bile duct. Internal fistulization was achieved by an 8 Fr. PTCD tube, after 4 days resulting in complete internal fistulization by clamping the PTCD tube. The diameter of the stent tube was gradually increased to 14Fr.. After cholangiography confirmed adequate flow through the bile ducts, the stent tube was removed on the 74th hospital day. During the eight months that have elapsed since removal of the stent tube, the patient has been followed on an outpatient basis; no signs or symptoms of restenosis have been observed.

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[in Japanese]

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