Early enteral nutrition is recommended as first-line nutritional management in patients with severe acute pancreatitis because it decreases the incidence of infection and mortality. However, it is not common in Japan. In this prospective multicenter study, we analyzed the current status of nutritional management in a series of patients with severe acute pancreatitis and highlighted the problems involved. This study enrolled 43 patients under the protocol to implement early enteral nutrition, aged 56.5±2.4 years who were admitted to 8 facilities 1.4±0.2 days after symptom onset between January 2009 and March 2011. The patients had a prognostic score of 4.0±0.2 and an APACHE II score of 13.7±1.3. Enteral nutrition was given to 30 (69.8%) patients according to the preset criteria for initiation of enteral nutrition, with only 4 (9.3%) of them receiving it within 48 h after admission (early enteral nutrition), showing that the median time from admission to initiation of enteral nutrition was 5.5 days. The reason for the delay in the initiation of enteral nutrition was, most frequently, elevated levels of pancreatic enzymes. In addition, conditions that made enteral nutrition difficult to initiate and that accounted for 51% of patients included ileus symptoms (22%) and circulatory insufficiency (12%). Enteral nutrition was discontinued in 3 (10%) patients because of severe diarrhea, pseudomembranous enterocolitis, or ileus symptoms, respectively, resulting in prolonged hospital stay (p=0.02) compared to other patients. There were no significant differences in either absolute levels (p>0.05) or time course changes in serum amylase levels (p=0.64) during the first 7 hospital days between patients with early enteral nutrition (n=4) and those who did not receive enteral nutrition within 7 hospital days (n=22); in general, serum amylase levels tended to decrease in both groups. There was also no intergroup difference in the level of C-reactive protein (p>0.05, p=0.97). No significant differences were found in the transition to operative treatment, infectious complications, days of intensive care unit stay, or days of hospital stay among 3 groups of patients, i.e., those who received early enteral nutrition, those who received enteral nutrition within 7 hospital days, and those who did not receive enteral nutrition within 7 hospital days. The results suggest that initiation of early enteral nutrition should be decided judiciously in about half of the patients with severe acute pancreatitis.

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A retroclival epidural hematoma (REDH) is a rare lesion that usually develops after a hyperflexion or hyperextension injury of the neck, often in a child. We describe the case of a 3-year-old boy fell from a swing who presented with a Glasgow Coma Scale score of 14 and neck pain. Neuroimaging identified a REDH. The child was treated conservatively and showed good outcome. This patient's mechanism of injury (MOI) was not significant (fall off a swing), although most of the reported cases were high energy accidents such as motor vehicle accidents. We consider the epidemiologic features (age and the MOI) of REDH are more various than previously thought. Physicians should think of REDH when the MOI is related to hyperflexion or hyperextension injury of the neck, regardless of the severity of MOI and age of the patient.

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We report a case of fulminant community-acquired pneumonia caused by Acinetobacter baumannii. A 23-year-old woman was admitted to the emergency ward with respiratory distress and shock. Her past medical history included alcoholism, pancreatitis, and liver dysfunction. Chest X-ray revealed a left lobar pneumonia. The patient was intubated and received fluid resuscitation. Meropenem, vancomycin, clindamycin, high-dose noradrenaline, and vasopressin were administered. Despite the intensive treatment, including percutaneous cardiopulmonary support, the patient deteriorated, and she expired 25 h after admission. Subsequently, Acinetobacter baumannii was isolated from cultures of tracheal aspirate and blood samples. Acinetobacter baumannii is one of the most important causes of nosocomial infection, but community-acquired infections due to this organism are rare. However, sporadic cases of community-acquired pneumonia have been reported, mainly from the tropical Asia-Pacific region. Most of the reported cases have been fulminant pneumonias with high mortality rates. Reports from the temperate zone are very rare, although recently a few cases have been reported from Japan. Because of its fulminant course and very poor prognosis, emergency physicians must be aware of this disease, and more aggressive treatment may be necessary.

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We report two cardiopulmonary arrest cases with tension pyopneumothorax. Case 1, a 36-year-old man with trisomy 21, had cardiopulmonary arrest upon hospital arrival. After cardiopulmonary resuscitation, imaging revealed fluid and gas accumulation in the left thorax, compressing and displacing the lung and mediastinum rightward. Although left thorax drainage released the purulent effusion and improved his circulation, he died on day 12. Streptococcus anginosus was cultured from the effusion. Case 2, a 57-year-old man with no apparent disease, had cardiopulmonary arrest upon arrival. After resuscitation, his circulatory state was unstable. Chest radiography revealed gas accumulation in the right thoracic septum, compressing and displacing the lung and mediastinum leftward. We punctured the right thorax at the second intercostal midclavicular line, but no gas exited. Although right thorax drainage released the purulent effusion and improved circulation, he died 8 hours after admission. Prevotella intermedia and Peptostreptococcus micros were cultured from the effusion. Previous reports of tension pyopneumothorax (pyothorax with elevated intrathoracic pressure in the affected side) have shown that patient background and causal pathogenic bacteria are similar to those in general pyothorax. The essential treatment for tension pyopneumothorax comprises early decompression and drainage of the pleural cavity followed by infection control.

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We describe a rare case of alcoholic ketoacidosis (AKA) with pancytopenia. A 67-year-old man with consciousness disturbance at home showed shock, hypothermia, and disturbance of consciousness on arrival at our emergency department. He had a history of rarely eating, and drank alcohol in excess. Blood tests revealed hypoglycemia and significant metabolic acidosis. AKA was thus suspected. With transfusion and glucose, his symptoms subsided. Pancytopenia developed on day 2. Bone marrow biopsy on day 5 revealed significant hypoplasia but no neoplastic changes. Serum copper and zinc levels on arrival were normal, but decreased significantly from day 2. The pancytopenia was attributed to malnutrition or deficiencies of microelement nutrients. We administered supplements including microelements. The pancytopenia showed amelioration. Myelogenesis was seen on bone marrow biopsy on day 57. He was transferred to another hospital on day 70. Pancytopenia reportedly occurs with generalized malnutrition, as well as copper and zinc deficiencies. AKA patients are more likely to be malnourished and have microelement deficiencies. Pancytopenia requires attention as an AKA complication.

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Introduction: Traumatic cerebral aneurysm can complicate severe head injury and has a high mortality rate. This report presents a case in which aneurysm coil embolization and two instances of therapeutic hypothermia were effective for treating traumatic pericallosal aneurysm rupture after severe head injury.
Case: A 33-year-old woman was admitted with a Glasgow Coma Scale score of 6 (E1V1M4) following severe head injury. Bilateral decompressive craniectomy was performed and subdural and epidural hematomas were removed under therapeutic hypothermia at 34°C. Her level of consciousness gradually improved. However, following seizures on day 17 after injury, three-dimensional computed tomography angiography revealed a falx subdural hematoma, severe brain swelling, and a right pericallosal artery aneurysm. Considering the brain swelling, coil embolization was performed. The patient was again placed under therapeutic hypothermia therapy and intracranial pressure and cerebral perfusion pressure were controllable. On day 64 after injury, the patient was able to walk and eat independently.
Conclusion: Coil embolization during a second craniectomy under a second instance of therapeutic hypothermia achieved a good outcome. It is necessary to consider a combined modality therapy such as craniotomy and intensive care strategies in cases of severe head injury complicated by aneurysm rupture.

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A 35-year-old woman was found with disturbance of consciousness in a park. Because empty cartridges were found near the woman, drug overdose was suspected and she was admitted to our emergency room. We discovered that she was 37 weeks pregnant and had been missing from her home because of fear of giving birth. Labor progress was confirmed by gynecological examination, and an emergency cesarean section was performed because she was due. The newborn infant showed absence of spontaneous breathing and was therefore intubated and mechanically ventilated. One day after birth, the neonate showed spontaneous breathing and was extubated. Twenty-two days after birth, he was discharged without any complications or drug withdrawal symptoms. Later, we found abnormally high serum Zolpidem levels in the mother and her newborn infant. Therefore, we diagnosed them with Zolpidem intoxication. Although usage of Zolpidem is relatively safe during pregnancy, its overdose and thus intoxication, as reported here, may affect the fetus. We should consider that if a pregnant woman is diagnosed with drug intoxication, the fetus also gets intoxicated. If toxic symptoms appear in the mother, the child will show more toxic symptoms.

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