Ultrasonography (US) is now readily available in emergency departments and intensive care units, and observing the inferior vena cava (IVC) with point-of-care US has become widely used to evaluate the circulatory dynamics. It is important to know about factors influencing the IVC diameter (IVCD) during the observation with US. In stable patients, the IVCD is usually measured in the supine position, however, reassessing it in the left lateral position is recommended in some cases. A sniff is appropriate for the evaluation of the respiratory response of the IVC. The measurement should generally be made at the hepatic segment and approximately 0.5 to 3 cm proximal to the ostium of the right atrium. The longitudinal view of the IVC is selected for the actual measurement, but understanding the shape in a cross-sectional view beforehand is helpful. The B- or M-mode should be used properly after considering the characteristics of each mode. As a substitute during the actual measurement, visual assessment of the IVC is also valuable, especially in critically-ill patients, because it can be quickly performed. The right atrial pressure is estimated based on the combination of the IVCD and its respiratory collapsibility in daily practice. The criteria used for estimating the right atrial pressure in Western countries have been revised in recent years. Meanwhile, the IVCD and indices of its respiratory changes have also been reported to be useful for the diagnosis and fluid management of decompensated heart failure, as well as for estimating circulatory volume depletion in early resuscitation and fluid responsiveness during controlled ventilation. Adding the observation of the IVC with point-of-care US in the acute care setting may thus enable physicians to perform less invasive and more accurate fluid therapy. Further evaluations based on standardized measurements and criteria are needed to confirm the utility of this modality.

View full abstract

Purpose: It is difficult to investigate the cause of unexpected death by autopsy in regions where there is no medical examiner system like Nobeoka City. This study evaluated the efficacy of the findings obtained from postmortem whole body computed tomography (PMCT) in addition to clinical examinations of out-of-hospital cardiopulmonary arrest (OHCPA) cases for identification of the causes of OHCPA and complications associated with cardiopulmonary resuscitation (CPR).
Subjects & Methods: The subjects were 180 cases out of 222 non-traumatic OHCPA cases between January 1, 2009 and December 31, 2011 (male/female 99/81, age 0-100 years: mean 74.4 years), who underwent PMCT due to unknown causes. The aim was to detect the cause of death and identify complications due to CPR (rib fractures, sternum fractures, and pneumothorax) with postmortem clinical examinations (prodromes, past history, physical findings, laboratory results) and the findings of PMCT. The study compared the confirmed causes of deaths with previously published data of postmortem autopsy in Kobe.
Results: The confirmed causes of deaths were cardiac disorders (ischemic and others) in 8.9% of patients, cerebrovascular disorders (subarachnoid hemorrhage etc.) in 8.9%, aortic disorders (aortic aneurysmal rupture etc) in 12.2%, respiratory disorders in 13.3%, aspiration/asphyxiation in 3.9%, and unknown causes in 41.1%. A comparison with the data from Kobe revealed that the ratio of cardiac disorders was lower (8.9 vs. 44.7%) and that of unknown causes was higher (41.1 vs. 4.7%), and the amplitude between them was almost same (35.8 vs. 36.4%). Compared with the results by autopsy, cardiac disorders (ischemic and others) could not be sufficiently confirmed by the PMCT findings. There was little difference between the ratio of cerebrovascular, aortic, respiratory and digestive-pelvic disorders. The ratio of confirmed causes of death by the findings of PMCT alone was 32.2%, most of which were cerebrovascular and aortic disorders, and by those of combined clinical examinations and PMCT was 26.7%, which included aspiration/asphyxiation, respiratory disorders and digestive-pelvic disorders, the total ratio resulting in 58.9%. The ratio of events associated with CPR was pneumothorax in 6.3%, rib fractures in 14.9%, and sternum fractures in 4.5%.
Conclusion: The PMCT findings could be helpful for the investigation of causes of death in the non-traumatic OHCPA cases due to unknown causes and the detection of CPR, especially chest compression, related complications in the region where no exploratory autopsy was available.

View full abstract

Background and Objective: The amendment to the Japanese Organ Transplant Law in July 2010 has allowed legal determination of brain death and organ donation from brain dead patients in children less than 15 years old. However, there has been only 2 cases of legal brain death in children since then. The actual situation regarding pediatric brain death is not fully understood, and the reason for its paucity has not yet been investigated. Regardless of organ transplant, we have performed general brain death determination prior to the amendment for neurological evaluation. Based on our experience, we have investigated the current situation regarding brain death in children and the reason for its paucity.
Patients: 3,721 children less than 15 years old who admitted to the PICU during a four-year period between July 2008 and June 2012.
Methods: The patients were categorized into pre-amendment or post-amendment depending on the timing of the brain death determination. Characteristics and result of determination were analyzed retrospectively through the medical records.
Results: There were 1,712 patients in the pre-group, and 2,009 patients in the post-group. Brain death evaluation regardless of transplant was performed on 16 cases in the pre-group, and 19 cases in the post-group. Of the patients who were indicated for evaluation, 50% were post-cardiopulmonary resuscitation in the pre-group, and 74% in the post-group, respectively. Admission from emergency room consisted of 94% and 89%, respectively. Only 3 cases in the post-group were evaluated as potential brain death, which consisted 0.1% of total admissions in PICU, and 7% of pediatric death.
Conclusion: The actual situation of pediatric brain death was analyzed in this study. Differences in the criteria for brain death and views on brain death may be contributing factors to its paucity.
All of facilities must be fully prepared for an efficient response in such situation.

View full abstract

Background: Bicycle accidents are one factor that causes unintentional traumatic injury in childhood. However, the risk of direct-impact handlebar injuries among children has not been generally recognized.
Objective: To examine characteristics of and risk factors for handlebar injuries among children.
Methods: A 12-year retrospective survey was undertaken of patients under 15 years of age with bicycle-related injuries admitted to our hospital between January 2000 and December 2011. Patients were divided into the direct-impact handlebar injury (HI) group and the non-handlebar injury (NHI) group.
Results: The HI group included 9 patients (7 boys and 2 girls; mean age, 8.6±3.4 [mean±SD] years) and the NHI group included 46 patients. In the HI group, mean Injury Severity Score (ISS) was 8.8±5.3, and mean length of intensive care unit (ICU) stay was 7.4±4.6 days. The prognosis was good in all patients. Injury sites were as follows: neck, 1 (tracheal injury); chest, 1 (chest bruise); and abdomen, 7 (hepatic injury, 3; pancreatic injury, 1; retroperitoneal hemorrhage, 1; renal injury, 1; abdominal wall and bladder injury, 1). Therapeutic interventions were performed in 3 patients: emergency surgery, 1; elective surgery, 1; and emergency transarterial embolization, 1. The other 6 patients were followed with close observation. There were no significant differences in age, sex, ISS, length of ICU stay and prognosis between the two groups. However, significant differences were seen in abdominal Abbreviated Injury Scale (AIS), which was higher in the HI group, and in head AIS, which was higher in the NHI group. Direct transportation from the scene of the accident occurred significantly more often in the NHI group, whereas transfer from another hospital occurred significantly more frequently in the HI group.
Discussion: One feature of handlebar impact injury among children was visceral organ damage despite the external physical appearance because the impact force from the bar-end was concentrated in a small area of the abdominal wall. The injury and/or present history also were misleading in that the injury appeared to be milder than it actually was. Preventive measures against direct-impact handlebar injury might be to revise the shape of the handlebar-ends and to equip the rider with a garment protecting the abdomen.
Conclusion: It should be emphasized that the direct-impact handlebar injuries in children may have the potential to cause severe damage to visceral organs; thus, initial evaluation of the injury should be performed with prudence.

View full abstract

The patient was an 83-year-old man undergoing maintenance hemodialysis. He was transferred to our hospital because of loss of consciousness at 2:00 a.m. His blood glucose was 22 mg/dl, and we administered intravenously 20 ml 50% glucose. Blood glucose increased to 128 mg/dl and consciousness improved. He was not a diabetic. We continuously administered 10% glucose at 20 ml/hr after admission, but he lost consciousness again at 7:00 a.m. on the same day because his blood glucose was 32 mg/dl. We learned from the primary care physician that cibenzoline succinate (CZ) had been prescribed to him for ventricular tachycardia that occurred during dialysis. We suspected that his low blood glucose level was drug-induced, and we started continuous infusion of a high dose of glucose. Disturbance of consciousness was improved by the intravenous drip of glucose. Since his blood CZ level was 1,330 ng/ml at the time of admission, we made a diagnosis of hypoglycemia induced by CZ. He needed hospitalization for 12 days because removal of CZ by dialysis appears difficult.

View full abstract

Infective endocarditis (IE) presents various complications. Here, we report two cases of rapidly progressing neurological symptoms due to IE complications. Case 1: A 57-year-old woman was hospitalized with toxic epidermal necrolysis. On hospital day 38, brain computed tomography (CT) revealed hemorrhage in the left occipital lobe. Following hematoma removal and decompressive craniectomy, repeated echocardiography showed no abnormal findings. On postoperative day (POD) 24, CT revealed a new hemorrhage and cerebral aneurysm in the peripheral left middle cerebral artery; however, cerebral angiography 7 days later showed that the aneurysm had disappeared. Transesophageal echocardiography on POD 26 showed vegetation on the mitral valve. Following mitral valve replacement, she was transferred to a rehabilitation hospital. Case 2: A 50-year-old woman was hospitalized with disturbance of consciousness and left hemiparesis. Magnetic resonance imaging showed cerebral infarction with right middle cerebral artery occlusion. Echocardiography showed vegetation on the aortic valve and replacement was performed. CT showed brain swelling with a midline shift on POD 1 and she underwent decompressive craniectomy, after which she was transferred to a rehabilitation hospital. To achieve a good prognosis it is necessary to consider the timing of surgery and intensive care strategies taking into account the complications of IE.

View full abstract

Deep venous thrombosis can cause serious complications such as pulmonary embolism. We herein report a case of collateral vein rupture associated with deep venous thrombosis resulting in retroperitoneal hemorrhage. A 75-year-old woman with a 1-week history of pain and swelling in her left lower extremity was transferred to our emergency department because of left-sided lumbar pain. A computed tomography (CT) scan revealed retroperitoneal hemorrhage and extravasation of the contrast media in the venous phase and deep venous thrombosis between the left common iliac vein and left popliteal vein. We suspected bleeding from the left ovarian vein and therefore hospitalized the patient for conservative medical management. On the second day, she underwent angiography to determine the cause of the anemia and CT revealed a recurrence of extravasation. However angiography did not reveal active bleeding. Therefore, the patient was fitted with an inferior vena cava filter and provided conservative medical treatment, after which her symptoms resolved. We surmised the deep venous thrombosis induced an increased perfusion flow in the collateral veins; the resulting increased venous pressure thus caused the rupture of the left ovarian vein. Clinicians must consider retroperitoneal hemorrhage when patients with deep venous thrombosis present with low back pain.

View full abstract

Reports of abuse of designer stimulant drug, frequently sold as ‘bath salts’ or ‘plant nutrition’, have increased dramatically in recent years, particularly among young people. We report a case of 30-year-old male who had taken a designer stimulant drug and subsequently lost consciousness on the next day. He was tracheally intubated after convulsion in the emergency room. He developed autonomic ataxia, hyponatremia, acidemia, and rhabdomyolysis. The titer of creatinine kinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) were increased to 70,842U/l, 939U/l, 1,051U/l, respectively, but improved after fluid resuscitation without renal failure. Gas chromatography - mass spectrometry (GC/MS) was used to detect the components of the drug. The major component was pyrovalerone, intake of which was proven in blood, urine and stomach contents using GC/MS; its concentration was 1.73μg/ml in the blood, 41.9μg/ml in the urine on day 1 and 0.001μg/ml in the blood, 0.108μg/ml in the urine on day 9. The patient was discharged from the hospital without any symptoms. Access to various designer stimulant drug is easy, fast and broad. Clinicians need to be especially vigilant in that overdoses of designer stimulant drug can be life-threatening, hence detailed analyses of the drugs are desirable.

View full abstract

The patient was a 4-year-old female. Two days prior to her transfer to our hospital, she started having repetitive vomiting. She was taken to the pediatric emergency room (ER) in the evening on the same day. Acute gastroenteritis was diagnosed following an examination at ER, and the patient was sent home. On the morning of her transfer to our hospital, she was found unconscious, and an ambulance was called. She was in cardiopulmonary arrest (CPA) when the ambulance arrived, and cardiopulmonary resuscitation (CPR) was performed en route to the hospital. The patient was in asystole on arrival at our hospital. CPR was continued. Return of spontaneous circulation was achieved 16 minutes after arrival at our hospital. Once the patient was hemodynamically stable with catecholamine administration, computed tomography (CT) was performed to diagnose the etiology. Gastric volvulus was suspected. While preparing for an emergency surgery, the patient went into CPA for the second time, and resuscitation was attempted again. This time however, she was unresponsive to the treatment, and passed away. This is a report on a pediatric case that suffered CPA which was suspected to be due to gastric volvulus, along with a review of the literature.

View full abstract

Cervical canal stenosis combined with intrauterine infection can sometimes cause pyometra among older women. We describe a 76-year-old female who was transferred to our emergency and critical care centre with dyspnea and diaphoresis. Upon arrival, she fell into cardiopulmonary arrest, from which she was rescued by cardiopulmonary resuscitation. Laboratory studies revealed sepsis and abdominal CT imaging confirmed pus in the uterus. We diagnosed septic shock arising from pyometra. The patient was placed in intensive care and the pus was removed by vaginal drainage. She recovered uneventfully and was discharged without hypoxic encephalosis. Pyometra should be considered as a possible cause of septic shock in elderly women.

View full abstract