Introduction: No previous data has been collected regarding the relationships between emergency medical practitioners and the family of deceased patients; therefore, the surveys of emergency physicians were conducted at their workplaces to examine their awareness and the actual circumstances they faced when speaking to the family of deceased patients.
Research Subjects: As of February 2011, 3,049 emergency physicians of the Japanese Association for Acute Medicine were surveyed.
Methods: After receiving approval from a research ethics committee at an affiliated institution and devising ethical considerations regarding the implementation of the research, unsigned, mail-in surveys were anonymously collected, their answers were automatically recorded, and statistical analyses were performed.
Results: Completed questionnaires were obtained from 860 emergency physicians, and the valid response rate was 28.5%. Physicians who were actively engaged in providing support to bereaved family members gave more consideration to items that are usually explained to bereaved family members in emergency situations. In addition, these physicians paid more attention to such items when bereaved family members were allowed to be with the deceased patient. The survey revealed that 38.4% emergency physicians preferred to undergo specialized training for providing support to bereaved family members. In the group that preferred specialized training, physicians struggled with providing support to bereaved family members in certain cases where the patient had committed suicide or had multiple or serious injuries. Furthermore, 87.1% physicians responded that they naturally learnt how to provide support to bereaved family members by observing senior physicians.
Conclusion: Even specialist physicians hope to receive effective training and to learn from experience regarding the difficulties and struggles while providing support to bereaved family members in emergency settings. Therefore, it is important to devise practical, simple, and effective learning methods and training content. Moreover, our results suggested that the quality of support could be improved by increasing the awareness regarding active participation in providing support to bereaved family members. Future studies need to investigate how emergency physicians can continue to foster their attitude to actively engage in providing support to bereaved family members in emergency settings.

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Introduction: Japan has had a paramedic service since 1991. These paramedics have since been permitted to administer medical treatments including infusion, tracheal intubation, and epinephrine injection for cardiopulmonary arrest patients. Further medical treatments are now being designed for blood sugar measurement and glucose injection for suspected hypoglycemia, β2 stimulant inhalation for severe asthma, and infusion for patients in shock. We surveyed technical, diagnostic and psychological levels of confidence in relation to these new treatments among Japan’s paramedics.
Methods: We conducted a survey of attitudes of active paramedics in Yamagata prefecture and sent a questionnaire to fire departments in September 2012. This questionnaire comprised questions on the 4 new medical treatments, and asked paramedics to self-evaluate their level of technical confidence on a scale of 1 to 10. Furthermore, we also asked whether fire stations and individual paramedics had medical liability insurance.
Results: A total of 233 paramedics were enrolled in this study. The average technical confidence scores for blood sugar measurement, glucose injection, β2 stimulant inhalation, and infusion for shock were 7.9, 6.6, 4.1, and 6.4, respectively. The scores for blood sugar measurement and glucose injection among paramedics authorized to perform adrenaline administration were significantly higher than for paramedics unauthorized to carry out that procedure. All fire departments had medical liability insurance; however, only 21 paramedics (9%) had individual liability insurance. With the updated service comprising the administration of new treatments, 63 paramedics (27%) thought that they would take out individual liability insurance.
Conclusions: We demonstrated that the surveyed paramedics have poor levels of self-evaluated technical confidence for β2 stimulant inhalation. It is assumed that a workshop on adrenaline administration for paramedics will help improve knowledge and skills for blood sugar measurement and glucose injection. Therefore, a workshop on β2 stimulant inhalation is now also needed so that paramedics can learn more about this procedure in addition to conventional adrenaline administration. The number of lawsuits is expected to increase since paramedics will now treat more serious cases as compared to the cases prior to the introduction of the updated service. Paramedics should take account of the medical liability insurance.

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Background: The pre-hospital evaluation criteria for children presenting as emergency cases were established in the Tokyo metropolitan region with the purpose of detecting pediatric patients requiring medical treatment at medical emergency centers, etc. and the practice thereof commenced in October 2009.
Purpose: Investigation into the validity of the pre-hospital evaluation criteria for children presenting as emergency cases.
Subjects: The subjects consisted of patients 15 years of age or younger who were directly transported to the National Center for Child Health and Development by ambulance during the 14-month period from February 2011 to March 2012.
Method: The medical records were retrospectively investigated. Emergency cases showing positive findings for pre-hospital evaluation items were defined as predictive cases. Emergency cases with no such positive items were defined as under-triage cases. Non-emergency cases with positive items were defined as over-triage cases.
Result: A total of 41 out of 2,707 cases were determined to be predictive cases. The great majority were endogenous cases, with central nervous system abnormalities the most common disease and abnormalities in the level of consciousness common as a positive item. A total of 69 out of 2,707 cases were classified as over-triage cases. Among these, 75% were febrile seizure cases. Meanwhile, 62 out of 2,707 cases were under-triage cases, in which the great majority patients suffering from trauma, anaphylaxis and seizures. Moreover, an association was observed between “circulatory failure” and the items included in the criteria. The sensitivity was 40% and the positive predictive value was 37%. As a result, adding the new items of “anaphylaxis” and “cluster seizures” to the pre-hospital evaluation criteria, and the adaptation of a trauma card, would thus allow the criteria to achieve a higher sensitivity, namely 75%.
Conclusion: Our findings indicated the low sensitivity of the current pre-hospital evaluation criteria for children presenting as emergency cases. In order to obtain a better sensitivity for such cases, we therefore propose the addition of two items to the pre-hospital evaluation criteria, namely “anaphylaxis” and “cluster seizures”, and the adaptation of a trauma card for trauma patients by the emergency team. Moreover, the items regarding “circulatory failure” for such child cases should also be reevaluated and modified as deemed necessary.

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Objectives: Water intoxication is often caused by polydipsia in psychiatric disorders such as schizophrenia. Patients with water intoxication sometimes develop rhabdomyolysis (RML). However, the underlying mechanism and risk of RML in these patients have not yet been elucidated. Therefore, we examined the pathogenesis and prognosis of RML in patients with water intoxication.
Methods: The characteristics of patients diagnosed with water intoxication from January 2006 to August 2012 were retrospectively examined. These patients were divided into RML and non-RML groups. The following data for the 2 groups were examined: patient background, laboratory data on admission, transition of laboratory data, intensive care unit stay length, hospital stay length, complications, and prognoses.
Results: 33 patients were diagnosed with water intoxication; among them, 18 (55%) also had RML. The median peak serum creatine kinase level was 22,640 IU/l (6,652-55,020 IU/l, interquartile range). There was no significant difference in serum sodium or plasma osmolality upon admission (p=0.354, p=0.491, respectively) between the groups. However, the serum sodium correction rate differed significantly between the groups (p=0.001). Acute kidney injury developed in 5 patients in the RML group. However, no patients required renal replacement therapy, and the renal function of all patients improved immediately. No cases of central pontine myelinolysis (CPM) or mortality were noted.
Conclusion: Patients with water intoxication often develop RML. Our findings here suggest that the onset of RML may be related to rapid serum sodium correction. RML is a complication of water intoxication that must be noted in conjunction with CPM.

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Background: Regional saturation of oxygen (rSO₂), also known as “tissue oxygen saturation” or “local mixed blood oxygen saturation”, indicates the overall oxygen saturation including the arteries, veins and capillaries. The change in the balance of oxygen supply and demand can be determined by measuring this value. Although protection of the patient’s brain is emphasized in cardiopulmonary arrest, no studies have investigated tissue oxygenation of the brain during resuscitation.
Objective: To clarify serial changes in cerebral rSO₂ during resuscitation of patients with out-of-hospital cardiac arrest.
Methods: We retrospectively analyzed date from patients with out-of-hospital cardiac arrest in whom cerebral rSO₂ were measured serially between March 2008 and March 2010. Patients were divided into the ROSC (return of spontaneous circulation) (+) group, ROSC (-) group, and PCPS (percutaneous cardiopulmonary support) group. Normal range of rSO₂ was determined from 15 healthy patients to be 71.2±3.9%.
Results: The ROSC (-) group consisted of 25patients (mean age, 71.0±15.9 [mean±SD] years), the ROSC (+) group 13 patients (72.1±9.6 years), and the PCPS group 5 patients (54.4±15.8 years). Chest compression only could not increase cerebral rSO₂, but rSO₂ markedly increased with ROSC. Mean rSO2 at ROSC was 43.2±14.1%, and it increased significantly after 10 minutes (55.7±12.3%; p<0.05) and 15 minutes (59.7±8.5%; p<0.01). In the PCPS group, rSO₂ values were 63.0±8.8% after 5 minutes, 66.2±5.7% after 10 minutes, and 68.1±4.6% after 15 minutes, significant increases compared with 48.4±8.9% at the time of PCPS application (all, p<0.0001).
Conclusions: Chest compression only could not increase cerebral rSO₂, but it increased gradually with ROSC. Cerebral rSO₂ increased promptly with application of PCPS.

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We report an elderly patient with acute kidney injury due to rhabdomyolysis from type A influenza virus. A 75-year-old man, with a long history in a mental hospital for schizophrenia, was diagnosed with influenza virus infection causing a fever. He was transferred to our emergency unit because rhabdomyolysis and acute kidney injury were indicated by his laboratory data the next day. We treated him in the intensive care unit. Although we administered massive amounts of intravenous fluid and used diuretics, he progressed to kidney failure, and received hemodialysis on the 2nd day. Then, he received 18 sessions of hemodialysis over a 34-day periods and was transferred to the previous hospital on the 52nd day. There are reports of acute kidney injury due to rhabdomyolysis from conventional influenza virus infection. On the other hand, there are few reports of cases due to A/H1N1 pdm (novel H1N1 influenza virus). Although there are reports of multiple organ failure including acute respiratory distress syndrome, it is noteworthy that this virus can cause only acute kidney injury as in the present case.

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Around 4,600 caffeine overdose cases a year have been reported in the US. However, it is relatively uncommon in Japan. The caffeine overdose is associated with life-threatening hemodynamic and neurological complications. In this paper, we report a case of caffeine overdose that was successfully treated with hemodialysis. A 26-year-old male took 25 g of caffeine to commit suicide and was taken by ambulance to our hospital. The patient was agitated and presented with tachycardia, tachypnea, muscle rigidity, tremor, and vomiting on admission. Electrocardiography revealed multifocal ventricular tachycardia (VT). The lethal dose of caffeine is about 10 grams and its half-life is 3 to 7 hours. Since the VT was refractory to lidocaine and the dose of his caffeine intake was high enough to give rise to hemodynamic collapse and persistent arrhythmia, we performed hemodialysis on this patient. After the hemodialysis, arrhythmia and other symptoms due to caffeine overdose rapidly disappeared, and the patient was discharged without any complications. Based on the clinical course we experienced, an early induction of hemodialysis is thought to be an effective treatment for a patient presenting with caffeine overdose.

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A 54-year-old man who had been diagnosed with hepatitis C at 30 years of age had been complaining of epigastralgia for two hours. His blood pressure was 88/58mmHg and his heart rate was 57/min. Physical examination revealed tenderness of the upper abdominal area. Blood tests revealed hepatic and biliary enzyme elevation and a high bilirubin level. High density from the right hepatic duct to the common bile duct was detected on pre-contrast CT and enhanced multiple tumors, predominantly in right hepatic lobe, were revealed by contrast enhanced CT. The patient was diagnosed as hemobillia due to hepatocellular carcinoma, ruptured into the biliary tract. Endoscopic hematoma evaculation was performed and epigastralgia subsided. Transcatheter arterial chemoembolization (TACE) was carried out three days later to prevent rebleeding and reduce the size of the tumors. The patient recovered and was discharged 24 days later. TACE was carried out again for hepatocellular carcinoma two and five months later but he died of hepatic failure seven months later.

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Streptococcal toxic shock syndrome (STSS) is attributed to “flesh-eating bacteria” because of its rapid progression and high mortality rates. Survivors often require amputation of the affected limbs. Here we report a case of widespread STSS that affected almost of all left lower limb and retroperitneum and that treated successfully with aggressive debridement and supportive care without amputation. A 41-year-old woman arrived at our emergency room in shock. Acute fulminant soft-tissue infection was diagnosed, and treatment was initiated to combat septic shock; we later diagnosed STSS according to the gram-positive bacteria isolated from a blister. Infection had spread throughout the ankle to the level of iliopsoas. Surgery was performed immediately. Because muscle tissue was unaffected, only necrosing tissue was debrided, and the retroperitoneum was left open until no necrotic tissue needed to be debrided. Postoperatively, the wound was monitored daily, with additional intensive care and debridement to ensure excision of all necrotic tissue and salvage of the limb. The current case indicates that prompt diagnosis and aggressive debridement can achieve a favorable outcome, including preservation of limb function, even in case of wide spread cutaneous STSS.

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The pandemic of influenza A/H1N1pdm09 infection occurred in 2009. We report a case of acute respiratory distress syndrome (ARDS) caused by the flu in a pregnant woman, who was treated with extracorporeal membrane oxygenation (ECMO). A 30-year-old woman at 31 weeks of gestation, who had been hospitalized due to pregnancy-induced hypertension, had fever. Subsequently her respiratory status worsened rapidly, and a Caesarean section was performed at 33 weeks of gestation. She was diagnosed with ARDS; hence, she was intubated. However, the hypoxia worsened, and she was referred to us for ECMO. On admission to our hospital, we immediately initiated veno-venous ECMO. Additionally, antibiotics and antiviral drugs were administered, and ECMO was continued for 88 h. Her respiratory status gradually improved, and she was extubated. The total ventilation time was 12 days, and she was discharged without sequela. Recently, ECMO was recognized as a method for management of ARDS. Pregnancy is a major risk factor and can lead to severe influenza; hence, the infection requires careful attention.

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Herein, we report 4 cases of superior mesenteric artery (SMA) occlusion in which angiography was effective for determining the appropriate treatment strategies, including interventional radiology (IVR). In 2 patients who were successfully treated by IVR alone, the occlusion site was distal to the origin of the middle colic artery, and angiography showed good visualization of the peripheral branches via collateral circulation. Both received thrombolysis, and the interval from the onset to blood flow resumption was 15 hours in one patient and 3 hours in the other. In the 2 patients who underwent enterectomy following IVR, the occlusion site was proximal to the origin of the middle colic artery and the peripheral branches were poorly visualized: In one patient, aspiration thrombectomy failed to restore blood flow, and in the other, thrombolysis plus aspiration thrombectomy restored good blood flow, although it took as long as 5.5 hours from the onset of occlusion. The viability of the intestines in cases of SMA occlusion may depend on the collateral circulation. If angiography shows poor development of collateral circulation and poor visualization of branches, the possibility of intestinal necrosis should be borne in mind, even if IVR restores the blood flow in the SMA stem and branches.

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