We reviewed the recent advances in the coagulation and fibrinolytic responses in patients at an early phase of trauma. Recently, the Educational Initiative on Critical Bleeding in Trauma (EICBT) proposed new clinical entities,“Coagulopathy of Trauma”and“Acute Coagulopathy of Trauma-Shock (ACoTS) ”. A new clinical entity must be clearly distinguished from other diseases and syndromes using definite diagnostic criteria. However, the EICBT failed to establish diagnostic criteria for these two clinical entities. Increasing clinical evidence suggests that the Coagulopathy of Trauma and ACoTS are equivalent to disseminated intravascular coagulation (DIC) with the fibrinolytic phenotype. Neither the Coagulopathy of Trauma nor ACoTS can be differentially diagnosed from DIC with the fibrinolytic phenotype, thus suggesting that these two concepts are not independent diseases or syndromes but instead are only vague clinical conditions. Misleading terms, such as Coagulopathy of Trauma and ACoTS without a clear definition or diagnostic criteria should not be used for the explanation of changes in coagulation and fibrinolysis in patients at an early phase of trauma. We emphasize that DIC with the fibrinolytic phenotype should be described in the same manner that it has been until recently.

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Background: Although we sometimes encounter cancer diagnosis during the course of diagnostic process after visiting an emergency department (ED), its detailed picture has not been fully clarified. Therefore we examined the incidence rate and the characteristics of patients diagnosed as having cancer after visiting our ED.
Method: We retrospectively investigated the medical records of all the adult patients who visited our ED between April and June 2007 (ER group) and extracted the patients with cancer which was newly diagnosed at ED or during the follow-up period. The same method was applied to all the adult patients who visited our outpatient department during April 2007 (control group). Access to our ED, cancer localization, diagnostic examinations, diagnostic process, presented symptoms, treatment, and patient outcome at 6 months were then compared between the two groups.
Result: During the study period, 48 of 5,587 patients (0.86%) were diagnosed as having cancer in the ER group, which was approximately one third the incidence rate in the control group (2.32%, p<0.001). Among patients 70 years of age or older, the incidence rate increased to 2.03% and 4.05%, respectively (p=0.04). The most common diagnostic examination among patients who were diagnosed at ED was computed tomography (78%), whereas that among patients who were diagnosed during the follow-up period was digestive tract endoscopy (67%, p<0.001). The most common chief complaint in the ER group was abdominal pain (31%), whereas in the control group, one third visited our hospital asymptomatically (p<0.001). Significantly fewer patients underwent radical therapy in the ER group compared with the control group (46 vs 80%, p=0.035), and survivors at 6 months were also fewer in the ER group (38 vs 60%, p=0.042).
Conclusion: Incidence rate of newly diagnosed cancer after visiting our ED was 0.86% among adult patients and 2.03% among patients 70 years of age or older, which seemed not to be negligible. We concluded that cancer should be included in differential diagnosis even for patients presenting in the ED.

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Objective: Epidemiological data on the vital signs and severity in patients with heat-related illness are rarely reported. The aim of this study is to investigate the independent risk factors for poor outcome in patients who are mechanically ventilated due to heat-related illness.
Methods: Data on patients suffering from heat-related illness admitted to emergency medical service centers throughout Japan from 1 June to 30 September 2008 were collected by the Heatstroke Surveillance Committee of the Japanese Association for Acute Medicine. Of 913 patients with heat-related illness, 77 were mechanically ventilated. Excluding patients with out-of-hospital cardiac arrest, cerebral infarction, and unknown outcome, 73 patients were included in this analysis. The patients were divided into a good outcome group (recovery without sequelae) and a poor outcome group (death and with sequelae).
Results: Forty-seven patients were in the good outcome group and 26 patients in the poor outcome group. There was no significant difference between the two groups in term of age, gender, or intensity of activity, consciousness level, pulse rate, respiratory rate, and body temperature at the scene. Significant difference between the two groups was found for systolic blood pressure and SpO₂ at the scene, and the interval from onset to hospitalization. Furthermore, significant difference was found between the poor outcome and good outcome groups in the following variables on arrival: arterial base excess (BE) (-9.5±5.9 vs. -3.9±5.9 mmol/l, p<0.001), serum creatinine (2.8±3.2 vs. 1.8±1.4 mg/dl, p=0.02), alanine aminotransferase [72 (32-197) vs. 30 (21-43) IU/l, p<0.001], and disseminated intravascular coagulation score (6±2 vs. 3±3, p=0.001). However, no significant difference was found in the interval from arrival to the start of cooling or in the interval from arrival to attaining 38°C. Systolic blood pressure and SpO₂ at the scene, and arterial BE were identified as independent risk factors for poor outcome.
Conclusion: The outcome of patients who are mechanically ventilated due to heat-related illness may not be affected by treatment after admission.

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Alcoholic ketoacidosis (AKA) usually occurs in patients with a history of prolonged excessive alcohol abuse and recent binge drinking followed by abrupt cessation of alcohol consumption. AKA patients usually visit a medical institution complaining of gastrointestinal symptoms. We report an atypical case of AKA presenting with consciousness disturbance after eating a high-fat meal. A 61-year-old man was brought to our emergency department by ambulance for suspicion of stroke owing to consciousness disturbance. He had a history of eating barbecued beef with beer the previous night. Because of his consciousness disturbance, the detailed medical history was uncertain. However, he had unexplained hypoglycemia with high anion gap metabolic acidosis and fatty liver, and we strongly suspected AKA. After hydration by intravenous administration of saline solution, dextrose and thiamine, his metabolic acidosis rapidly improved. A history of alcohol abuse and high serum β-hydroxybutyrate concentration were subsequently confirmed, and the diagnosis of AKA was finally made. Our case suggests that a high-fat meal can induce AKA without abrupt cessation of alcohol consumption and that AKA should be considered when encountering patients presenting with unexplained high anion gap metabolic acidosis with hypoglycemia and fatty liver, even if the past history of alcohol abuse is unknown.

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A 21-year-old male who had been crushed in a car due to a traffic accident was transferred to the emergency department. His vital signs were stable but the contrast-enhanced computed-tomography (CT) scan showed a retroperitoneal hemorrhage and the extravasation of contrast dye at the level of the 4th lumbar artery. A follow-up CT scan on the following day indicated a 4th lumbar artery pseudoaneurysm. Open abdominal surgery was performed because the patient was relatively young and interventional radiology (IVR) would have been difficult due to the small margin between the pseudoaneurysm and the abdominal aorta. The avulsion injury of 4th lumbar artery was directly repaired with pledgets. Cases of lumbar artery injury induced by iatrogenic factors, such as a renal biopsy and lumbar disc surgery, have been previously reported. There are also some reports of a lumbar artery pseudoaneurysm occurring secondary to a lumbar fracture and pelvic fracture in trauma patients. However this is the first case report of a pseudoaneurysm due to a traumatic avulsion injury of the lumbar artery. A careful approach is therefore the key to effectively treating a traumatic avulsion injury of the lumbar artery because of the difficulties in applying IVR.

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We describe a patient who survived 2009 influenza A/H1N1-associated fulminant myocarditis with critical care including percutaneous cardiopulmonary support (PCPS). A 24-year-old female was diagnosed in November 2009 with influenza A and received oseltamivir. Although her fever decreased, she experienced frequent vomiting and diarrhea 5 days after disease onset and was transfered to our hospital the following day. Electrocardiograms showed ST-segment elevation in leads II, III, aV_F, and V_3-6, with increase in creatine kinase and troponin T levels. Cardiac ultrasonography revealed marked overall reduction of wall motion, establishing a diagnosis of myocarditis. Following ICU admission, general management was provided by intraaortic balloon pumping (IABP) with catecholamines, with continuous homodiafiltration (CHDF) to address acute renal failure. Next morning, cardiopulmonary arrest was happened and PCPS was initiated. Following PCPS circuit replacement on day 4, cardiac function gradually improved till weaning from both PCPS and IABP on day 7 and CHDF on day 8. Prolonged mechanical ventilation due to airway hemorrhage and left pulmonary atelectasis ended with tracheal tube removal on day 15. She was discharged without neurological sequelae on day 33. PCPS, initiated without delay upon in-hospital cardiopulmonary arrest, enabled her survival with standard supportive care alone.

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Atypical antipsychotics like quetiapine cause few extrapyramidal adverse effects. Used prominently in psychiatry, these drugs are increasingly used by emergency patients to intentionally overdose. A psychiatric outpatient in her 40s presented with hemodynamic instability as well as impaired consciousness and generalized tonic seizures. The patient came in with empty blister packs, suggesting she had taken a massive dose of quetiapine (8,700 mg). The dose taken was presumed to be toxic, and initial treatment involved gastric lavage and activated charcoal. The patient received fluid therapy and respiratory and circulatory care in the intensive care unit; the patient's level of consciousness and general condition improved on day 3 of hospitalization, so the patient was discharged. Biological specimens such as serum and urine were cryopreserved, allowing retrospective analysis. In a clinical setting like a general hospital, acute poisoning is normally suspected because of results of a simple urine drug screening kit and a history of medication, but a kit may fail to detect quetiapine. Quetiapine is a new drug and has reportedly caused deaths in Japan and abroad. An analysis that reveals quetiapine may lead to a definitive diagnosis of quetiapine poisoning, and a prompt diagnosis should help in guiding treatment.

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