Background: Prompt detection and identification of the cause of hypoglycemia are important in emergency medical settings.
Purpose: To investigate the characteristics of emergency visits for hypoglycemia cases.
Subjects and Methods: Of the patients transported to our hospital by ambulance from April 1, 2005, to August 31, 2009, those whose initial blood glucose levels were less than 60 mg/dl were enrolled as the subjects of this study; patients with cardiopulmonary arrest and those who were less than 6 years old were excluded. The age, sex, blood glucose levels, cause of hypoglycemia, the symptoms, and the outcomes of the study subjects were investigated.
Results: The study involved 487 (1.3%) of the total of 37,044 cases transported by ambulance; the mean age of these patients (mean ± standard deviation)was 67.8±16.9-years, there were 297 males, and the mean blood glucose level was 35.8±14.7 mg/dl. The most commonly encountered presentation was altered consciousness, with 3-digit-code on the Japan coma scale (JCS) (160 patients), while 121 patients had no symptoms. The cause of hypoglycemia was insulin in 148 cases, oral hypoglycemic agent in 138, chronic alcoholism in 46, sepsis in 40, liver cirrhosis/liver failure in 34, malignant tumors in 32, malnutrition in 29, dumping syndrome in 8, endocrine disorders in 4, and others in 8. With regard to the relationship between the symptoms and the blood glucose levels, blood glucose levels were significantly lower in the group with lower consciousness levels (p<0.001). The incidence rate of hypoglycemic hemiplegia was 1.8%. The percentage of patients with no symptom and JCS 3-digit-code was higher in the group with non-diabetic medical agent-related hypoglycemia than in that with diabetic medical agent-related hypoglycemia (p<0.05). Five patients had irreversible neurological sequelae; all of these patients were ≥75 years old, and 3 were under treatment with a sulfonylurea (SU) agent. All of the deaths after hospitalization were from the group of non-diabetic agent (n = 48), and the death rate in this group was 23.9%.
Conclusion: The incidence rate of non-diabetic medical agent-related hypoglycemia was 41.3% among hypoglycemic cases transported by ambulance; many of these patients had markedly consciousness disturbance and all of the deaths after hospitalization were from this group. Irreversible neurological sequelae were often seen in elderly patients under treatment with a SU agent. The incidence rate of hypoglycemic hemiplegia was 1.8%; caution for differentiation from stroke is needed in these patients.

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Introduction: Laboratory testing plays a minor role in screening for fractures in blunt trauma patients. Its main value is in the assesssment of co-morbidity. We investigated the association between elevated D-dimer levels and fractures.
Hypothesis: Elevated D-dimer levels are associated with fractures in blunt trauma patients not including polytrauma.
Methods: A retrospective cohort study was performed on blunt trauma patients referred to our emergency department (ED) over two years (2008-2010). Patients were eligible for inclusion if they were referred within 24 hours after injury. Patients with polytrauma, head injury, aortic injury/disease, malignancy, and thromboembolic tendency were excluded. A D-dimer assay was obtained up on ED arrival. Receiver-operator characteristic (ROC) curve analysis was performed to evaluate the cut-off value of D-dimer.
Results: Of 341 eligible patients, 210 (61.6%) had fractures (Fx group) and 131 (38.4%) did not (non-Fx group). Compared to the non-Fx group, the Fx group was significantly older (61±23 vs. 49±23 yr, p<0.01) and had higher D-dimer levels and ISS (DD, median (IQR): 8.4 (3.0-24.9) vs. 1.4 (0-3.1), p<0.01, ISS, mean±SD: 7.4±3.9 vs. 2.8±2.6, p<0.01). ROC analysis revealed the area under the curve was 0.81 (95% CI 0.77-0.86) and identified the D-dimer level of ≥4.5μg/ml as an optimal cut-off value, with a sensitivity of 69.0%, specificity of 84.7%, and a positive predictive value of 90.6% for detecting fractures.
Conclusions: Our findings suggest that an initial D-dimer assay may be efficient in screening for fractures in blunt trauma patients. Further study in the prospective setting is warranted to establish its efficacy.

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A 61-year-old male was transported to our hospital with a chief complaint of fever and general fatigue. He had undergone laparotomy for a Klebsiella pneumoniae liver abscess (KLA) three years prior to his presentation. As ultrasonography and enhanced computed tomography (CT) revealed an abscess in the lateral segment of the liver, antibiotic administration was started. On day 2 of hospitalization, the patient underwent catheter drainage of the liver abscess and received a diagnosis of KLA by culture of the discharge. On day 2, although the sedative had been discontinued after tracheotomy, his consciousness was not improved. On day 10, enhanced CT revealed a slight increase in the abscess size, the additional appearance of a psoas abscess and spondylitis at L3 and L4, so resection of the lateral segment of the liver was performed on day 12. A lumbar puncture performed on day 18 due to the continued disorder of consciousness led to the detection of Enterococcus faecium by culture. After the administration of Linezolid, the patient’s fever gradually disappeared and his consciousness improved, although his vision was still affected. The patient was diagnosed with endophthalmitis by an ophthalmological examination and transported to another institution for specialized ophthalmic treatment.

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A 58-year-old man was transferred to our hospital because of out-of-hospital cardiopulmonary arrest. On arrival, the patient had spontaneous circulation. A cardiac ultrasnography showed normal heart measurements and function. Although the electrocardiogram (ECG) recorded in the emergency room showed sinus rhythm, the ambulatory ECG using the emergency medical system indicated a complete atrioventricular (AV) block, resulting in cardiac arrest. The coronary angiography (CAG) did not show significant organic stenosis. On careful questioning after full recovery of his consciousness, the patient admitted to having had experienced chest discomfort before he collapsed. We suspected coronary spasm and performed CAG with a spasm provocation test. Severe spasm was induced at the right coronary artery (RCA). ¹²³I-15-(p-iodophenyl)-3-methyl pentadecanoic acid (BMIPP) scintigraphy showed that BMIPP uptake was decreased in the RCA regions. In addition to optimal medical therapy, a permanent pacemaker was implanted. Patients with vasospastic angina usually have a good prognosis. In some cases, vasospasm-induced ischemia causes life-threatening ventricular arrhythmias, a transient complete AV block, syncope, and even sudden cardiac death. The protocol for evaluating patients after cardiac arrest due to coronary spasm has not been established. Furthermore, the indications for pacemaker implantation in patients with coronary spasm have not been clearly established.

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We reported a case of cervical necrotizing fasciitis requiring tracheotomy, but effectively managed by negative pressure wound therapy (NPWT). A 63-year-old man suffering from swallowing pain was transferred to our hospital for the treatment of cervical abscess. He was in shock state on admission and after the initial stabilization, surgical debridement was performed. NPWT using Vacuum Assisted Closure^® (V.A.C.^®) system was instituted from the day 6. The aim was to achieve the negative pressure at the wound, where there was an interspace between a tracheostomy orifice and the tube. So, polyurethane foam (V.A.C. GranuFoam) was placed into this interspace and the neck flange of the tracheostomy tube as a unit created a negative pressure environment, that was effective for preventing the spread of infection. On the 56th day, the wound was closed by reconstructive surgery using a pectoralis major myocutaneous flap. Thus, NPWT would be beneficial for the treatment of cervical necrotizing fasciitis even in patients requiring tracheotomy.

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A 22-year-old woman attempted suicide by overdosing on prescription drugs (lithium carbonate, sodium valproate (VPA), etc.). Her condition was stable on admission except for consciousness, but decreased blood pressure and polyuria were observed thereafter. Polyuria was attributed to diabetes insipidus caused by the lithium carbonate. Since blood levels of VPA were high (190.2μg/dl), continuous hemodiafiltration (CHDF) was initiated. In addition, levocarnitine chloride solution and lactulose were used concurrently. CHDF was discontinued after one session and the patient was discharged on day 6. Lithium overdose can cause fatal arrhythmia. This patient overdosed on lithium carbonate in addition to long-term use. Moreover, VPA overdose can cause problems including brain edema and death. This patient had a high blood VPA level. Lithium has a low protein binding rate, as does VPA when overdosed. CHDF was therefore performed and satisfactory recovery was made. The VPA taken by this patient was a sustained release preparation and the likely course of changes in internal absorption, blood levels, and protein binding rate were difficult to predict. Ultimately, we determined the treatment plan through measurement of blood levels of VPA. When managing cases of complex drug intoxication, sequential and rapid toxicology/drug analysis and a system for measuring blood levels are considered essential.

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A 79-year-old woman with chronic rheumatoid arthritis was admitted to the orthopedics department for osteosynthesis because of right femur fracture. The patient experienced abdominal pain 13 days after the operation. There were diffuse peritoneal signs on palpation, and free intraperitoneal air, fluid retention, and an enlarged gas-filled uterus were observed on abdominal computed tomography scan. A large volume of foul purulent discharge was obtained via transvaginal drainage, then pyometra perforation was suspected as the cause of panperitonitis. Laparotomy revealed perforation at the uterine fundus, and subsequently, abdominal total hysterectomy was performed. The patient received intensive care after surgery because she was in a state of septic shock and eventually recovered well. Generally, pyometra is considered a chronic and benign infection of the uterus that usually occurs in aged women. However, some previous studies in the literatures have reported that occasionally, in case of perforation, pyometra can result in panperitonitis. In such cases, this benign disease can be fatal and rapid diagnosis and appropriate treatment is essential for avoiding mortality. We should consider pyometra perforation as a cause of panperitonitis, especially in the case of aged women presenting with acute abdominal pain.

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Non-occlusive mesenteric ischemia (NOMI) is difficult to diagnose in the early phase and often has a poor prognosis. Circulatory failure is a known risk of NOMI. A 74-year-old man with accidental hypothermia complicated by NOMI was admitted to our hospital in an unconscious state. On admission, circulatory failure was observed, and his rectal temperature was 22.7°C and systolic blood pressure was 72 mmHg. Rewarming was performed by warm fluid infusion using a heating system. His temperature increased to approximately 36°C after 4 hours of rewarming along with temporary stabilization of hemodynamic parameters; however, hyperlactatemia and circulatory failure resistant to fluid infusion and inotropic support gradually developed. He developed disseminated intravascular coagulation, and antithrombin and recombinant human soluble thrombomodulin therapy was initiated. Forty-eight hours after admission, abdominal computed tomography findings along with hemorrhagic ascitic fluid collected by paracentesis suggested acute mesenteric ischemia (AMI). Emergency enterocolectomy was performed; however, the patient died 4 days after admission. Histopathological findings included transmural necrosis without blood clotting, which was consistent with the diagnosis of NOMI. Because accidental hypothermia can induce AMI, early diagnosis and management are imperative.

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A 75-year-old woman was admitted to our hospital because of cough and dyspnea. She underwent sigmoidectomy for sigmoid colon cancer and left hepatectomy for liver metastasis at the age of 67. The patient had been undergoing systemic chemotherapy for multiple lung metastases. On admission, her general condition was poor, and ultrasonographic examination revealed a massive retention of pericardial effusion, on the basis of which cardiac tamponade was diagnosed. Subsequently, emergency pericardiocentesis was performed, and 800 ml of hemorrhagic fluid was aspirated. The cytology of the effusion was class V, and a diagnosis of carcinomatous cardiac tamponade (CCT) due to pericardial metastasis of colon cancer was made. Her general condition immediately improved, and she was discharged on the 17th hospital day. However, the patient died of progressive lung metastases 9 months later. CCT due to cardiac metastasis of colon cancer is an important oncologic emergency, and the number of cases is expected to increase. Emergency pericardiocentesis is recommended to prevent incidences of sudden death, thus elongating life expectancy and improving the patient’s quality of life. Emergency care physicians must therefore consider emergency pericardiocentesis when presented with cases of CCT.

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A penetrating injury in the internal thoracic artery due to a knife is a rare occurrence. A 21-year-old male presented at a hospital alone and soon thereafter fell into shock in the emergency room. The patient had left-side severe hemothorax due to the presence of both an internal thoracic arterial injury and lung injury. An operation was performed through a mid-sternal incision following a primary survey based on the JATEC (Japan Traumatic Evaluation and Care) criteria. The hospital could diagnostically only perform chest X-rays, but could not conduct any other detailed examinations, and this was the first such case that had ever presented at our secondary emergency medical institute. An internal thoracic arterial injury can be treated by various methods, including surgical treatment, embolization and conservative therapy. This traumatic case was difficult to successfully treat and therefore tested the limits of this facility. However, the selected patient management made it possible to prevent the occurrence of trauma death, due to the fact that the staff followed the JATEC criteria. The primary survey conducted according to the JATEC procedure was thus found to be effective for the successful surgical treatment of an internal thoracic arterial injury due to a penetrating trauma at a secondary emergency medical institution.

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This report presents a case of multiple rib fractures in a patient with long-term use of corticosteroids for Wegener’s granulomatosis. A 49-year-old male was transported to the emergency room (ER) with thoracic injuries and hemorrhagic shock. He had a history of using corticosteroids. Oral intubation and chest drainage were performed at the ER, followed by intra-vascular embolization for a ruptured spleen. Internal fixation for multiple rib fractures using positive pressure ventilation was initiated in the ICU; however, it was extremely difficult to wean the patient from the mechanical ventilator. Thoracic regional anesthesia was introduced for pain management. However, it was impossible to wean the patient from mechanical ventilation. Surgical stabilization of the multiple rib fractures was performed on the 15th day after admission. The postoperative course was uneventful, and the patient was successfully weaned from the ventilator. The patient discharged on the 60th hospital day. Early surgical stabilization for multiple rib fractures should be considered based on the patient’s condition. This is especially true in compromised patients, such as the elderly and those with a long history of using corticosteroids, as well as for the patients for whom fixation is considered to be difficult to achieve by innerfixation.

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