It is important to assess the severity of patients' conditions using various markers upon their arrival to emergency centers. In this study, we assessed the levels of B-type natriuretic peptide (BNP), cardiac troponin I (cTnI), D-dimer, Hb, T-Bil, BUN, and s-Cr for this purpose. Out of 1954 patients who were consecutively transferred to Kitasato University Hospital Emergency Center from June 2007 to June 2008, 1253 patients without cardiopulmonary arrest on arrival were assessed with regard to the relationship between their outcome and blood BNP, cTnI, D-dimer, Hb, T-Bil, BUN, and s-Cr levels on arrival. We divided the patients into two groups according to whether they died in hospital and whether the causes of their disease were intrinsic or extrinsic, and then made comparisons between groups. The blood concentrations of BNP, cTnI, D-dimer, T-Bil, BUN, and s-Cr were significantly high while that of Hb was significantly low in the hospital death group. In multivariate analysis, age, BNP, D-dimer, and T-Bil in the intrinsic group were found to be independent predictors of hospital death; whereas, D-dimer and T-Bil were found to be independent predictors of hospital death in the extrinsic group. In particular, the cardiogenic cases in the intrinsic cause group revealed a sensitivity of 93.3%, a specificity of 83.9%, a positive predictive value of 38.9%, and a negative predictive value of 99.1% with regard to hospital death using variables selected by the stepwise method. In the extrinsic cause group, D-dimer demonstrated a sensitivity of 83.3%, a specificity was 76.0%, a positive predictive value of 22.0%, and a negative predictive value of 98.3% for predicting hospital death with a cut-off value of 10.14μg/ml. The D-dimer level of patients upon their arrival to emergency rooms is an important factor for predicting patient prognosis. Although multiple factors were related to prognosis in the intrinsic cause group, a 10.14μg/ml D-dimer level may be a good indicator of high-risk patients.

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Purpose: The number of Accredited Training Institutions for Fellowship and Senior Fellowship of the Japanese Association for Acute Medicine (accredited institutions) exceeds 400. These institutions play a central role in emergency care of the community, however, the volume of emergency patients that they receive remain unknown. The purpose of this study was to investigate the number of emergency admissions at accredited institutions.
Methods: Diagnosis Procedure Combination (DPC) data for 6 months from July 2008 were used. Of the 1,559 DPC and those preparing hospitals, 220 emergency medical service centers and Accredited Institutions for Senior Fellowship were defined as critical care hospitals, 200 Accredited Training Institutions for Fellowship as certified hospitals, and 1,139 as general hospitals. Of the DPC-reimbursed admissions, the numbers of scheduled, emergency and ambulance admissions were investigated by hospital group.
Results: The total, emergency, and ambulance admissions were 4,200,000, 1,900,000, and 500,000, respectively. Of these, critical care hospitals received 30.3%, 27.7%, and 32.1%, and certified hospitals 18.0%, 17.5%, and 19.2%, respectively. The median ratios of emergency and ambulance to total admissions in each hospital were 45% and 13% in critical care hospitals, 49% and 13% in certified hospitals, and 54% and 10% in general hospitals, respectively. Inestigating the numbers of emergency admissions for the Major Diagnostic Category (neurological, respiratory, cardiological, digestive, and trauma & toxicological disorders), critical care hospitals received 29.4%, 24.7%, 31.3%, 25.2%, and 28.9% of admissions, respectively, The corresponding percentages for certified hospitals were 18.0%, 17.3%, 18.2%, 17.4%, and 17.1%, respectively. The ratio of scheduled admissions was greater in critical care and certified hospitals than in general hospitals.
Conclusion: Approximately half of the DPC-reimbursed emergency and ambulance admissions were received by critical care and certified hospitals.

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This report details a successful treatment case of post-traumatic acute respiratory distress syndrome (ARDS) with severe flail chest by airway pressure release ventilation (APRV). A 63-year-old male was seriously injured in a traffic accident and brought to our hospital. He was diagnosed with multiple rib fractures, massive hemothorax, flail chest, lung contusion with blunt chest trauma and fractures of the pelvis and extremities. After two emergency thoracotomies for the thoracic hemorrhage, his pulmonary function was markedly deteriorated and acute respiratory distress syndrome developed. The Ventilator was set to pressure support (PS) mode (PS 15cmH₂O, PEEP 15cmH₂O), but the PaO₂/F_IO₂ ratio decreased to 45mmHg. We reset the ventilator to APRV mode for this critical respiratory status. After a few hours, the PaO₂/F_IO₂ ratio improved to 175mmHg. After getting this improved respiratory state, surgical stabilization for the multiple rib fractures could be performed safely on the 3rd day of admission. And he was weaned from the mechanical ventilation on the 8th day. We therefore concluded that APRV is a preferable mode of ventilator support for post-traumatic ARDS with severe flail chest.

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We report here a case of nephrogenic diabetes insipidus revealed only after hospitalization for trauma. A 27-year-old man with open fractures was admitted for emergency surgery. The patient was fasted preoperatively and received crystalloid solution intra- and postoperatively. He had presented with polyuria on arrival and serum sodium levels subsequently increased to 161 mEq/l at 18 hours after arrival. At the same time, diabetes insipidus was suspected from the massive amounts of dilute urine and hypernatremia. Crystalloid solution was replaced with 5% glucose and oral intake was resumed, which gradually alleviated the hypernatremia. He did not respond to desmopressin and was subsequently diagnosed with nephrogenic diabetes insipidus (NDI) by the water restriction test. It became apparent that the patient had polydipsia from early childhood and actually had congenital NDI. Infusion of crystalloid accompanied by cessation of oral intake would rapidly lead to hypernatremia and hyperosmolar dehydration in NDI and can leave neurological sequelae in severe cases. Fluid management in the perioperative period is also challenging. NDI is not a common disorder, but can result in serious adverse outcome if not noticed in the emergency department. Emergency physicians should be cognizant of this disorder to ensure that life-threatening situations are avoided.

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We observed two cases of acute hepatic failure resulting from heat stroke. When we used the standard criteria for determining whether emergent liver transplantation should be used to treat acute hepatic failure, we found that liver transplantation was indicated in both cases. In one case, living donor liver transplantation was performed, and in the other artificial liver support therapy was administered without liver transplantation. Afterward, the patients' general condition improved in both cases, as did their liver function without neurologic sequelae. Severe heat stroke easily leads to neurological dysfunction and/or impaired coagulability. For that reason, it is possible that the encephalopathy and disseminated intravascular coagulation observed in these heat stroke patients could have been caused not only by acute hepatic faiulre but also by the heat stroke itself. Therefore, it is difficult to judge the indication for liver transplantation according to the existing standard criteria for emergent liver ation. In addition, as the patient condition of severe heat stroke is characterized by multiorgan involvement, such conditions can be indicated for liver transplantation. Therefore, artificial liver support therapy as bridge to regeneration and transplantation had better be performed on acute hepatic failure secondary to severe heat stroke.

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Rapid multidisciplinary cooperation is a key factor for the successful treatment of severe Fournier's gangrene: a case report. We report a case of life-threatening Fournier's gangrene. A 79-year-old man was urgently brought in upon collapsing on the floor at home. In the emergency room, he had a high fever and quickly developed hypotension with metabolic acidosis. His scrotum, upper thighs, and abdomen were swollen and necrotic. He was diagnosed with septic shock due to Fournier's gangrene with an Acute Physiologic and Chronic Health Evaluation (APACHE) II score of 33 and Fournier's gangrene severity index score of 15. The patient was urgently transferred to the ICU and immediately treated according to the Surviving Sepsis Campaign Guidelines 2008. After an emergent conference with multidisciplinary surgeons, he was taken for urgent debridement. Postoperatively, direct hemoperfusion with a polymyxin-B immobilized column and low-dose steroids were introduced, as well as mechanical ventilation. Additional irrigation and debridements were performed as needed. He was weaned from mechanical ventilation on hospital day (HD) 9. After discharge from the ICU on HD12, he underwent colostomy for fecal diversion. On HD 62 he was transferred to a long term rehabilitative health care facility. We conclude that early treatment involving the cooperation of multiple specialists is important for the successful treatment of severe Fournier's gangrene.

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A 22-year-old woman ingested approximately 240 ml of a disinfectant in a suicide attempt. Chest radiography and echocardiography revealed bilateral, pulmonary edema and apparent cardiac depression, respectively. We suspected cardiac failure and pulmonary edema induced by naphazoline. Symptoms improved following administration of dobutamine, phentolamine, olprinone, and other drugs. The patient was discharged in good condition on day 13 after hospitalization. Although the clinical symptoms suggested naphazoline intoxication, the patient insisted that she had drunk Makiron and thrown away the emptied container. Since currently marketed Makiron S does not contain naphazoline, we initially had difficulty identifying the causative agent. However, drug and toxicological analyses of blood from the patient and on-site inspection confirmed that she had ingested a disinfectant similar to Makiron that contained naphazoline. The pulmonary edema seen in the present case was attributed to synergy of increased pulmonary vascular permeability caused by adrenaline and an idiopathic reduction in cardiac function. In consideration of the pharmacological mechanisms, we initiated treatment with an α-blocker. Following initiation of concomitant PDE III inhibitor administration, marked improvements in cardiac index and pulmonary edema were observed. While acute naphazoline intoxication manifests as various clinical symptoms, no cases of pulmonary edema accompanied by impaired cardiac function as described herein have been reported. The present case was therefore considered to be of importance.

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The patient was a 70-year-old woman who experienced breathing discomfort and requested emergency assistance. When placed in the ambulance, she had pulseless electrical activity (PEA), but spontaneous circulation returned after cardiopulmonary resuscitation (CPR) performed by emergency medical personnel for about 1 minute, and she was brought to our hospital. When she arrived, PEA had recurred, but spontaneous circulation returned after CPR by hospital staff members for 8 minutes. Contrast-enhanced CT of the chest showed emboli in both pulmonary arteries, and a diagnosis of pulmonary embolism was made. Because the patient's circulatory dynamics and respiratory status had both stabilized, she was admitted to the ICU with the intention of performing anticoagulation therapy alone. However, 6 hours after admission, she had lapsed into a state of shock. Echocardiography showed that the evidence of right heart strain was tending to improve. Abdominal ultrasonography revealed an echo-free space in the abdominal cavity. Contrast-enhanced CT of the abdomen showed massive hemorrhagic ascites and a lacerated liver, the diagnosis was hemorrhagic shock secondary to liver damage caused by sternal compression. When a patient has received CPR it is necessary to treat the underlying disease while constantly bearing in mind the possible development of complications associated with resuscitation.

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