Background: The TRISS method, which is generally used for predicting trauma patient outcomes, was produced based on North American trauma cases. For Japanese patients, the model might be improved by specification to cases in Japan. The TRISS method predicts patient outcomes with five items, including systolic blood pressure (SBP). However, the prediction can not accommodate hospital patients who have abnormally high SBP on arrival.
Aim: We assess the influence of SBP on some outcome prediction models and assign a new score to achieve better outcome prediction for patients with high SBP.
Material and methods: We used data from the Japanese Trauma Data Bank (JTDB) of blunt trauma cases recorded with no missing items during 2004-2009 (n=22,283). We used a modified score that assigns a score of 2 to cases with SBP higher than 180 mmHg to produce outcome prediction models using these new scores. The accuracy and AUC of models using the TRISS method, prediction outcome model with a conventional TRISS score, the proposed method, and a generalized additive model were assessed. Data from The National Trauma Data Bank (n=1,078,289) were used for comparison with JTDB data.
Results: The survival rate curve with respect to SBP in JTDB showed a peak at 120 mmHg. Comparison between JTDB and NTDB revealed that the survival rate of Japanese trauma cases with high SBP values is lower than that for North American cases. Validation testing showed that the TRISS method and outcome prediction model with a TRISS score are insufficient to predict outcomes for blunt trauma patients with high SBP values. That tendency was not apparent for NTDB cases.
Discussion: Results suggest that Japanese trauma cases are more closely related to head injury and aging. Complex prediction models exhibit good performance, but their practical use demands careful examination. The proposed method might be useful for Japanese patients with high SBP.
Conclusion: Scoring of the TRISS model in Japan can be improved for cases with high SBP values.

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Acute carbon monoxide (CO) poisoning is common, but the role of hyperbaric oxygen (HBO) therapy remains controversial. To evaluate the current situation regarding CO poisoning and HBO therapy, we sent a questionnaire to all 218 emergency medical centers in our country asking the approximate number of patients treated per year for CO poisoning, whether the center had an HBO chamber, protocols for HBO therapy, and details of patients with persistent neurological sequelae. We received 108 valid responses (50%), including 45 (42%) from centers who treated 5-10 cases per year and 38 (35%) from centers who treated <5 cases per year. Forty-five centers (42%) had an HBO chamber, of which 40 used their chambers to treat CO poisoning. Twelve centers used HBO therapy for all cases of CO poisoning, and 12 used HBO therapy only for cases with delayed neuropsychological sequelae. HBO therapy protocols were highly variable. Twelve patients with delayed neuropsychological sequelae were reported, all of which developed within 30 days. HBO therapy was performed in 8 of these 12 cases, with a range of 1 to 80 sessions. HBO therapy for CO poisoning remains controversial and differs depending on the treatment center and the attending physician. It is necessary for our country to establish guidelines for HBO therapy through rigorous clinical trials.

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Triage DOA (Sysmex Corporation) has been used to date in tertiary emergency centers, in carrying out simple drug screening from urine samples. In November, 2010, a urinalysis kit INSTANT-VIEW M-I (TFB Inc.) became available domestically. Accordingly, a comparative study of both kits was carried out at our institute based on the outcomes of drug analyses. The subjects were cases in which it was determined that examination was necessary at the time of initial treatment for emergency room, where urine sampling was possible, during approximately 8 months from December 28th, 2010 to August 30th, 2011. Triage DOA and INSTANT-VIEW M-I tests were carried out, and drug analysis using Gas Chromatograph Mass Spectrometer and Liquid Chromatography - tandem Mass Spectrometry was carried out in the forensic medicine department of our university on 45 cases observed to be positive for one or more item. As a result of the comparative study, INSTANT-VIEW M-I was found to require simple operation and a shorter time. Triage DOA, on the other hand, was simpler to use with respect to deciding the outcome. Regarding the efficiency of drug testing, sensitivity was higher in INSTANT-VIEW M-I, and specificity was higher in Triage DOA. The false positive rates for tricyclic antidepressants and benzodiazepines were high in both kits; these kits must be used with the understanding that there will be false positives (false negatives) in simple screening tests.

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We report a serious case of pulmonary thromboembolism (PTE) -a common post-orthopedic surgery complication-caused by prolonged casting. A long leg cast was applied in a 39-year-old man for Achilles tendon rupture on the right side. After approximately 3 weeks, he developed exertional dyspnea; a week later, he suddenly developed severe dyspnea at rest and required immediate hospitalization. The patient eventually developed tachypnea and experienced restlessness. We diagnosed PTE based on his condition and physical examination. He was intubated and placed on percutaneous cardiopulmonary support (PCPS) because of circulatory collapse. Thereafter, pulmonary arteriography was performed, and substantial emboli were detected in both pulmonary arteries. Therefore, catheter-directed fragmentation was performed, and standard anticoagulant therapy was administered. The patient's cardiopulmonary condition improved gradually; therefore, we discontinued PCPS and performed extubation. The Achilles tendon was sutured, and he was discharged 29 days after hospitalization. According to the American College of Chest Physicians (ACCP) guidelines, the need for thromboprophylaxis while casting lower limbs is controversial. Casting for Achilles tendon rupture results in PTE with almost the same frequency as that observed in elective hip replacement. Therefore, thromboprophylaxis or early surgical intervention should be considered while applying casts.

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An intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) should be used as lifesaving treatment for patients with conditions refractory to medical treatment. If improvement is still not seen, left ventricular assist device (LVAD) implantation or heart transplantation is the only way to save the life of the patient. However, because the number of institutions that perform heart transplants is limited, it is expected that the number of severely affected patients with circulatory support devices, who require emergency transport, will increase. Transporting these patients over long distances is an unresolved problem. The power of the internal battery in the device will not last en route. Helicopters are a better choice from the perspective of transportation speed, but the cabin is narrow and the available electric power is not sufficient. We transported patients with IABP by land in disaster support vehicles, which are large bus-sized fire engines. It has sufficient electrical power of up to 20 A. An increased number of patients will likely need to be transported under emergent conditions to other hospitals. We conclude that prior consultation regarding transport and actual transport simulations between medical and fire departments of each region will lead to increased survival.

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