Objectives: Symptoms of acute myocardial infarction (AMI) can be atypical, and some patients with AMI do not use an ambulance to travel to the emergency department (ED). The purpose of this study was to evaluate the characteristics of patients with AMI who do not arrive by ambulance (i.e., walk-in patients).
Methods: A retrospective study was performed for all ST-elevation myocardial infarction (STEMI) patients who presented to the ED from April 1, 2006 to March 31, 2012 in an urban ED in Japan. We compared baseline characteristics and the initial management of patients who arrived by ambulance with those of walk-in patients. We also compared the severity and prognosis of AMI.
Results: Data were collected from 362 patients. Of these, 95 (26.2%) arrived as walk-in patients and 267 (73.8%) arrived by ambulance. There was no significant difference in age and sex ratio between the groups. The onset-to-door time of the walk-in group was significantly longer than that of the ambulance group (median, 3 hours [IQR: 1-10]) vs. 2 hours [IQR: 1-4]), respectively, p<0.0001). Significantly fewer walk-in patients had chest symptoms (64.2% vs. 77.9%, respectively, p=0.01), but the proportion of patients with diabetes did not significantly differ between groups. The door-to-ECG time for the walk-in group was significantly longer (median, 10 minutes [IQR, 7-16] vs. 6 minutes [IQR: 3-8], respectively [p<0.0001]). The door-to-balloon time of the walk-in group was also significantly longer (median, 129 minutes [IQR: 99-160] vs. 104 minutes [IQR: 78-135], respectively [p<0.0001]). Peak CK and the proportions of patients with Killip IV class AMI, ventricular assist devices, and complications were not significantly different in the 2 groups. The length of hospital stay was significantly shorter for walk-in patients (median, 15 days [IQR: 12-22] vs. 17 days [IQR: 14-23], respectively, [p=0.03]). However, the length of ICU stay and the rates of inhospital death were not significantly different between the groups.
Conclusion: Walk-in AMI patients had longer onset-to-door time and were more likely to have chest symptoms than such patients who arrived by ambulance. The door-to-ECG time and the door-to-balloon time were also longer for walk-in patients. It is necessary to educate patients without chest symptoms to visit to the ED sooner, and construct more effective hospital triage procedures to properly screen for AMI in patients who present to the ED without using an ambulance.

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A 69-year-old man with Fournier gangrene was transferred to our emergency department. He had experienced dysuria and had self-inserted a straw into his external urethral orifice. His pubic region became remarkably enlarged 2 days later, and a diagnosis of Fournier gangrene was made at another hospital. His consciousness was clear, respirations were 31/minute, pulse was 122/minute, and his blood pressure was 150/85 mmHg on arrival. Redness, swelling, and subcutaneous emphysema were present from the trunk to the bilateral upper thighs around the perineum, and a foul odor of sake lees was noticed from the incised area of the perineum. Retrograde urography revealed injury to the urethra. The Fournier gangrene had improved almost completely by disease day 46 after antimicrobial agent administration, incision and drainage, debridement, and daily irrigation had been performed. The patient had a history of untreated diabetes, and drainage from the wound area on the first day revealed Candida glabrata, suggesting that the causative pathogen was Candida. Fournier gangrene is a comparatively rare disease, and reports assuming the causative pathogen to be a fungus are extremely rare. In patients compromised by a disease such as diabetes, fungus may also be considered as a causative pathogen of Fournier gangrene.

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We present the case of a patient who sustained a vertebral artery injury due to a stab wound to the neck. The 76-year-old male injured himself with a rake at a slippery sea-shore location. He was transferred to the nearest hospital in the late afternoon, and a left vertebral artery injury was suspected on plain and contrast-enhanced CT. After sunset on the same day, he was transferred to our institution for endovascular treatment. Because available time of emergency helicopter service in Japan is limited to daylight hours, he was transferred by ambulance, which took nearly 2.5h. During the transfer medical staff held his head to prevent additional injuries due to unexpected rolling or bouncing in the ambulance. Fortunately no harmful event occurred, and he was successfully treated. Although endovascular treatment is available at a limited number of institutions, patients with a suspected vertebral artery injury should be transferred to such an institution. If the transfer distance is long, examinations for the injury should be minimized and transfer by helicopter should be considered as early as possible. If a helicopter is not available, care should be taken to minimize the stress experienced by the patient and medical staff during the transfer.

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A 33-year-old primipara was transferred to our hospital after suffering massive uterine hemorrhage and shock one hour after normal delivery. Seven minutes after arrival, she displayed pulseless electrical activity (PEA), but was successfully resuscitated following nine-minute cardiopulmonary resuscitation (CPR). Transcatheter arterial embolization (TAE) was performed and she was admitted to intensive care unit (ICU). Following admission to ICU, the patient was diagnosed with disseminated intravascular coagulation (DIC) caused by amniotic fluid embolism. In addition to DIC treatment, she received methylprednisolone therapy for three days and underwent a two-day plasma exchange. On the 19th day of treatment, she developed cerebral venous sinus thrombosis and we started anticoagulant therapy. On the 23rd day of treatment, the patient again had uterine hemorrhage and underwent hysterectomy on the same day. She waspathologically diagnosed with Type 1 retained placenta (trapped placenta) and amniotic fluid embolism. The patient was discharged on the 134th day of treatment with a modified Rankin Scale of 1. Because amniotic fluid embolism is rare and has a poor prognosis, diagnosis and treatment of the disease require that different medical departments make quick judgments and have a cooperative system for intensive care in place.

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The ventricular assist device (VAD) has been successfully used in the treatment of end-stage heart failure, particularly as a bridge to heart transplantation, in Japan. We report a case of intracerebral hemorrhage (ICH) in a patient supported by VAD. The patient was a 41-year-old woman diagnosed with dilated cardiomyopathy. Medical treatment was provided but her heart failure worsened; she therefore underwent bi-VAD implantation as a bridge to heart transplantation. Three months after implantation, the patient experienced consciousness disturbance and right hemiparesis. Computed tomography revealed a massive ICH in the left frontal lobe. According to our protocol for the management of ICH, we immediately administered recombinant coagulation factor IX (nonacog alfa) 1,000 IU, vitamin K 10 mg, and fresh-frozen plasma 5U. However, the patient reported right hemiparesis and disturbance in consciousness; hematoma removal and decompressive craniectomy were therefore performed. The patient recovered without any neurological deficits and is now waiting for a heart transplant. The number of patients supported by VAD is increasing in Japan; therefore, neurosurgeons should have accurate knowledge of the various problems associated with VAD.

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A 74-year-old male was urgently transported to our Emergency Department (ED) because of massive bleeding in his perineal area. He had lost his balance and fell while standing on a chair of approximately 50 cm in height on the scene. A laceration in the perineal area of approximately 3 cm in width was identified and the paramedics applied pressure using gauze to reduce the heavy bleeding. On arriving at ED, he was alert and hemodynamically stable. Urethral catheter was inserted in the perineal wound directly, and pressed manually to control bleeding. Enhanced CT showed leakage of the contrast medium into the perineal tissues. Emergency angiography showed extravasation from the right internal pudendal artery, which was embolized using gelatin sponge. Retrograde cystography showed leakage from the urinary bladder as an extraperitoneal bladder injuly, so suprapubic drainage was constructed, and indwelling urethral catheter was inserted. Twenty-nine days later, the urethral catheter was removed and he was able to urinate on his own. He was discharged after one month hospitalization without any sequelae. Our minimum invasive strategy to control bleeding in a short time was more effective than a surgical approach in the pelvic cavity.

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A 74-year-old male was injured when he fell 2.5 meters while working on a building. Although a pelvic fracture was not seen radiographically, contrast computed tomography (CT) revealed hemopneumothorax with multiple left rib fractures and a very large retroperitoneal hematoma with L1-L5 transverse spinous process fractures. Angiography was performed to evaluate the retroperitoneal hematoma, and several areas of active bleeding from a branch of the lumbar artery (L1) were identified. Transcatheter arterial embolization (TAE) was performed to stop the hemorrhage. On the third day, endotracheal intubation was performed with ventilator support for CO₂ narcosis. A tracheotomy was performed on the 17th day because of complications such as pneumonia and atelectasis. The clinical course was uneventful, and the patients was transferred to a different hospital for rehabilitation. Although conservative medical treatment is effective and the prognosis is good in many cases of transverse spinous process fractures, some patients have severe complications. Lumbar transverse spinous process fractures are rarely complicated by lumbar artery damage; however, the lumbar artery bleeding that accompanies these fractures can be fatal and necessitates rapid performance of TAE.

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