Traumatic pneumothorax can progress to tension pneumothorax, which is a cause of preventable trauma death. Diagnosis must therefore be achieved without delay. Chest X-ray is performed in a supine position for the initial evaluation if patients have risk of cervical spine injuries or injuries affecting vital signs. However, nearly half of all traumatic pneumothoraces, known as occult pneumothoraces, are undetectable on supine chest X-ray. Use of ultrasonography to diagnose pneumothorax is relatively new, and diagnosis is based on the interpretation of the pleural line and underlying artifacts. The pleural line represents the parietal and visceral pleural layers in normal subjects, and corresponds to the interface between the parietal pleural layer and air in the thoracic cavity in cases of pneumothorax. Many prospective studies have recently evaluated the utility of ultrasonography to diagnose traumatic pneumothorax. These studies revealed that sensitivity ranged widely (46.5-100%), but ultrasonography was more sensitive than supine X-ray in each study, and was useful for detecting both occult pneumothorax and clinically significant cases. The negative predictive value was > 90% in all studies, meaning ultrasonography is useful for excluding traumatic pneumothorax. Further evaluations are needed to confirm whether adding ultrasonography for detecting pneumothorax in the initial trauma evaluation improves patient care or prognosis. In the future, ultrasonography during the initial trauma evaluation will evolve from focused assessment with sonography for trauma (FAST) to extended FAST (EFAST).

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Objective: This study was intended to set cut-off values for serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) as criteria for performing abdominal enhanced computed tomography (CT) in the diagnosis of blunt liver injury.
Method: Among patients with blunt trauma who were transported to the Teikyo University Trauma and Critical Care Center between January 1993 and April 2006, 1,018 cases who were brought in within 3 hours after injury and underwent abdominal enhanced CT were examined. Their medical records were investigated to determine age, gender, AST, ALT, injury severity score (ISS), the mechanism of injury, outcome (alive or dead), liver injury detected or not detected on CT and whether or not invasive procedures or laparotomy were performed when liver injury was found.
Results: Liver injury was detected on CT in 191 of the 1,018 patients examined. The median values of AST, ALT, ISS and age were 350 IU/1, 261 IU/l, 22 and 27, respectively, in patients with liver injury and 55 IU/l, 40 IU/l, 17 and 35, respectively, in those without liver injury. Significant differences in AST, ALT, ISS and age were found by the Mann-Whitney U-test between patients with and without blunt liver injury (p<0.001).
When the cut-off values obtained of AST and ALT were set at 165.5 IU/l and 130 IU/l respectively using the receiver operating characteristic (ROC) curve analysis, a good balance between sensitivity and specificity was obtained. AST showed a sensitivity of 88.0%, specificity of 83.0%, positive predictive value (PPV) of 54.4%, negative predictive value (NPV) of 96.8% and area under the curve (AUC) of 0.920. For ALT, the sensitivity as 83.8%, specificity 86.8%, PPV 59.5%, NPV 95.9% and AUC 0.928. Twenty patients with AST < 165.5 IU/l and ALT < 130 IU/I had liver injury but none of these patients died of liver injury. One of these 20 patients underwent transcatheter arterial embolization (TAE) for liver injury, and another one patient underwent laparotomy related to the liver injury.
Conclusion: The values of AST and ALT could be a useful marker to exclude severe blunt liver injury that requires intervention or laparotomy.

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Objective: Chest tube insertion is not always necessary for patients with mild pneumothorax. The ‘air-width,’ which is defined as a maximal width of free air space in the pleural cavity measured by computed tomography (CT) imaging, may be a good marker for the indication of chest tube insertion.
Methods: We retrospectively analyzed patients who were brought to our hospital's emergency department (ED) and diagnosed with a traumatic pneumothorax by thoracic CT imaging on arrival. Pneumothoraces which did not require initial chest tube placement were evaluated. CT images were then reassessed to measure air-widths and pneumothoraces were divided into 2 groups: the large air-width group (≥10mm) and the small air-width group (<10mm). Pneumothoraces in each group which did not have chest tube insertion at the time of the ED evaluation were then assessed for insertion later in the hospital course by a search through their medical records. The receiver-operating characteristic (ROC) curve was used to assess if an air-width of 10 mm is the optimal cut-off point.
Results: Out of 78 pneumothoraces, 51 cases did not receive chest tube insertion while in the ED. When assessed by air-width, the large air-width group contained 8 cases which did not receive a chest tube and the small air-width group had 43 cases not treated by chest tube. Comparatively, 4 of the 8 cases (50%) without initial chest tube insertion eventually needed chest tube placement later in their hospital course in the large air-width group while the small air-width group had 4 out of 43 cases (9.3%) which needed chest tube placement later on. Multiple logistic regression analysis revealed that an air-width ≥10mm was the only independent risk factor for chest tube insertion (odds ratio = 9.75; confidential interval 1.74-54.78). The area under the ROC curve for the necessity of chest tube insertion in pneumothorax was 0.850 and Youden index showed that the optimal air-width cut-off point was 10.9 mm.
Conclusions: Traumatic pneumothoraces whose air-widths are smaller than 10mm based on CT imaging obtained during their ED assessment can be managed safely without chest tube insertion. Thus an air-width greater than 10mm may be an optimal cut-off point. This value may also be easy to remember while managing patients in a busy environment.

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Acute aortic dissection requires an immediate accurate diagnosis, intensive care and surgery because it is a life-threatening disease. Six cases of acute aortic dissection that were diagnosed later are herein reviewed. Although all patients consulted the emergency room, four arrived by ambulance and two walked in during the night or on the weekend. Four patients complained of chest and/or back pain, while the other two complained of a transient loss of conscious or general fatigue, respectively. Two patients were hospitalized; one complaining of chest pain was suspected to have food poisoning, while another with conscious loss was suspected to have cerebral infarction. The other four patients went home without a definitive diagnosis because symptoms were ameliorated. The patient hospitalized with food poisoning went into shock 8 hours later, and was diagnosed with an aortic dissection by computed tomography. The other hospitalized patient was diagnosed by computed tomography on day 18. Two of the four patients who went home presented with cardiopulmonary arrest within two days. The remaining two patients consulted outpatient clinics the next day and were thus definitively diagnosed. It is important that we examine even the cases those symptoms and progress are atypical without excluding the aortic dissection.

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A 68-year-old woman on long-term glucocorticoid treatment for rheumatoid arthritis presented to our hospital with a chief complaint of palpitations. She was diagnosed with paroxysmal supraventricular tachycardia and received antiarrhythmic medication, without any increases in systolic blood pressure. A reassessment of her clinical condition revealed abdominal pain with signs of generalized peritonitis. Computed tomography detected ascites and an abscess on the anterior surface of the lower lumbar vertebrae and sacrum, suggestive of pyogenic spondylodiscitis. During emergency laparotomy, infectious ascites was present and the superior portion of the abscess had ruptured into the peritoneal cavity. The abscess was incised and drained. A broad-spectrum antibiotic and an agent to cover MRSA were administered since the patient was an immunocompromised host. After identifying the pathogen, Escherichia coli, the antibiotic regimen was tailored and continued for 4 weeks. She did not undergo any medical procedures prior to this event and had no symptoms of a urinary tract infection. We hypothesize that bacterial translocation from the gut resulted in bacteremia which seeded the pyogenic spondylodiscitis.

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A 76-year-old women receiving warfarine anticoagulant for atrial fibrillation,suffered cerebral infarction. She was transferred to our hospital with disturbance of consciousness and was diagnosed by MRI with cerebral infarction. She had severe anemia and intra-abdominal fluid collection, so intra-abdominal hemorrhage was suspected. Enhanced CT showed an aneurysm in the epiploic artery. Ruptured visceral artery aneurysms are usually treated by the laparotomy or the endovascular intervention. In this case, a laparoscopic surgery was selected because the endovascular intervention was thought to be difficult due to the aneurysm location in the peripheral of the left gastroepiproic artery. For unruptured aneurysms, the laparoscopic surgery has been indicated recently. In this case, the ruptured aneurysm was treated with laparoscopic surgery due to its location and to stable vital signs of the patients. She had an uneventful postoperative course and resumed anti-coagulation therapy on the next operative day. She was transferred on the 37th hospital day to another hospital for the rehabilitation. The present case of the ruptured epiploic aneurysm complicated with cerebral infarction allows us to learn the following: if the aneurysmal location is confirmed and patient's condition is stable, it is possible to achieve success with minimally invasive laparoscopic surgery.

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Although the usefulness of brain hypothermia for postresuscitative encephalopathy in children attracts attention in recent years, there are no definite evidence about the cooling strategy such as target temperature and duration. We herein report the good neurological outcome of postresuscitative encephalopathy following drowning in a 6 year-old male whose brain temperature was slowly rewarmed from 34°C due to coexisting accidental hypothermia. His estimated maximum cardiac arrest time interval could be 30 minutes. Spontaneous breathing occurred at 6 minutes, and light reflex emerged at 40 minutes after the recovery of spontaneous circulation. Rectal temperature, 31°C on arrival, was rewarmed to 33.9°C before ICU admission. Thereafter forehead deep temperature had been monitored as brain temperature, which was slowly rewarmed from 34°C to 36°C over 11 days with the use of the water-cooling blanket system. He was weaned from ventilator on day 18 and became possible to eat, walk by himself and speak a few words at half a year later. From a long term neurologic prognostic aspect, the slowly rewarming strategy of the brain temperature from 34°C could therefore be effective for a pediatric case of postresuscitative encephalopathy with accidental hypothermia.

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