Background: Seizure is the most common reason for transport to the hospital by ambulance. It is important to assess both the airway and respiratory status, to provide oxygen, and to assist ventilation as necessary. Object of this study is to analyze about risk factors for hypercapnia after seizure.
Patients and Method: From January 2008 to December 2010, the records of venous blood gas taken from the patients under fifteen years old transported to hospital because of seizure were reviewed. Hypercapnia was defined as a partial pressure of carbon dioxide (PaCO₂) over 65 mmHg, indicating respiratory failure.
Results: Over the study period, 2105 patients were transported to our emergency room by ambulance of which 799 patients had seizures. Blood gas samples were collected in 627 patients, and only 21 patients were hypercapnic. A significant difference existed with difference in presence of vomiting and status epilepticus as evaluated by the multiple linear regression analysis.
Discussion: Risk factors for hypercapnia are presence of vomiting and status epilepticus. It is possible that seizureassociated ventilatory failure is the direct reason for impaired consciousness during transport. Therefore, it is essential to provide oxygen and artificial ventilation.
Conclusion: When a patient presenting seizure is being transported, it is important to concentrate on controlling seizure and respiration. The potential role of capnography during transport is an area that warrants future research.

View full abstract

Psychological conditions of physicians before, during, and after doctor ambulance (DA) and doctor helicopter (DH) operations were investigated. A questionnaire survey was conducted with physicians involved in DA/DH operations. The number of valid responses was 283 (a valid response rate of 73%). The survey inquired physicians about their feelings and actions before, during, and after operations. Furthermore, their mental health was measured using the General Health Questionnaire (GHQ). Results indicated that physicians had a sense of duty for their job. However, physicians also felt anxious before and during operations, because they did not have sufficient information and were unsure of their ability to deal with the situation and the patient. After the operation, they shared their experiences and feelings with their colleagues. The GHQ indicated that 24.4% of the participants were at high risks of mental health problems. Those at high risks felt anxiety before the operation, because the situation might go beyond their abilities, and because they might get criticized. During the operation, they experienced negative feelings, such as anger and a sense of helplessness. It was indicated that some physicians involved in DA/DH operations felt a mental burden and were in an unhealthy mental conditions. Based on the above results, it is suggested that development of organized support systems are needed for physicians in DA/DH operations, including pre-education and training focusing on their anxieties and fears during operations, as well as measures to deal with them.

View full abstract

Acute infectious purpura fulminans (AIPF) is a rare life-threatening disease that causes septic shock and disseminated intravascular coagulation, with localized purpura of the extremities. However, it has not been well documented. Herein, we describe the pathology of AIPF in relation to the presence of super-antigens. A 74-year-old woman was brought to the hospital with disturbed consciousness. Six hours after, the patient progressed into septic shock and developed localized purpura over the extremities. On the 4th day, the skin began to peel, which resulted in dry gangrene. Streptococcus pneumoniae was identified from blood cultures taken on the 5th day. Therefore, we diagnosed the patient with AIPF. However, despite providing intensive care, the patient died on the 16th day. Owing to the rapid onset of skin symptoms, we suspected the involvement of super-antigens in the pathogenesis of AIPF. On the basis of a previous report that suggested a relationship between super-antigens and AIPF, we evaluated the patient for the presence of such an association. However, we did not detect any super-antigens. There is a significant need for future studies to evaluate the association between super-antigens and AIPF, including screening for the presence of other super-antigens that were not measured in this study.

View full abstract

A 61-year-old woman with a history of diabetes mellitus arrived at our hospital's emergency department in hypoglycemic coma following loss of appetite for 3 weeks. Initial blood glucose level was 24 mg/dL. Although she responded to intravenous glucose administration and recovered from the coma, electrocardiography demonstrated ST elevation in leads II, III and aVF, and echocardiography revealed asynergy at the cardiac apex. This episode was followed by slightly increased serum levels of creatine kinase MB and troponin I. ST elevation had almost returned to baseline at 1 hour after admission, but 2 hours later, negative T waves were observed in leads II, aVF and V6. Coronary angiography revealed no critical coronary artery disease, and left ventriculography showed apical and inferior wall hypokinesis. Takotsubo cardiomyopathy was diagnosed. Her clinical course was uneventful. Although the electrocardiogram (ECG) showed deep T-wave inversion in leads II, III and aVF, echocardiographic evaluation on hospital day 7 showed resolution of the left ventricular dysfunction. Only a few cases of takotsubo cardiomyopathy after hypoglycemic coma have been reported. When prolonged anorexia causes hypoglycemia in a patient and an abnormal ECG is observed, the possibility of takotsubo cardiomyopathy should not be overlooked.

View full abstract

A 20-year-old female was admitted to our emergency room with an acute right back pain followed by progressive dyspnea. CT scan showed right-sided pleural effusion and pulmonary collapse with mediastinal shift. Based on the result, she was diagnosed with spontaneous hemopneumothorax. Seven hundred milliliters of bloody effusion were drawn out through a chest drain. Her vital signs were normal in spite of the bleeding. Further diagnosis by bronchial arteriography revealed the presence of abnormal vessel near the second right intercostal artery which branched from right bronchial artery. Subsequent embolization of the vessel with Histoacryl^® stopped the bleeding as indicated by clear effusion. Three days after the procedure, 400 mL of intrathoracic remnant hematoma was removed by performing video assisted thoracic surgery. During surgery, no sign of bleeding was detected around the apex of pleural cavity where cord-like tissue connected with parietal pleura. Hence we confirmed that the abnormal vessel was the responsible lesion. Given the ideal postoperative recovery course, she was discharged on the 8th postoperative day, especially at the case that does not have a shock or the high-risk case under thoracoscopic surgery.

View full abstract

A 58-year-old man was transferred to our hospital because of multiple organ dysfunction and myocardial infarction. He had been complaining of vomiting, diarrhea and malaise for 3 days before admission. On examination his vital signs were stable. Laboratory data showed severe kidney and liver dysfunction as well as disseminated intravascular coagulation. Electrocardiography and echocardiography showed evidence of inferior and right ventricular myocardial infarction. Coronary angiography showed total occlusion of the proximal segment of the right coronary artery and 75% stenosis of the left main trunk. There were no symptoms or physical finding suggesting shock. After initiation of intra-aortic balloon pumping and continuous hemodiafiltration, his multiple organ dysfunction improved rapidly. He underwent coronary artery bypass grafting on the 7th hospital day and was discharged on the 39th hospital day. It was suggested that low cardiac output due to right ventricular infarction and left ventricular dysfunction dehydration gradually caused his multiple organ dysfunction in the absence of sign of cardiogenic shock. Clinicians should remember the potential for atypical presentation of cardiogenic shock, especially due to right ventricular dysfunction.

View full abstract

We described a case of an 85-year-old man with subscapular arterial injury who was successfully treated by covered stent placement. He experienced anterior shoulder dislocation after a bike accident. Upon admission, his blood pressure was slightly low, and after manipulative reduction of the dislocation, the blood pressure decreased further. Subsequently, extravasation around the axillary artery was noted on contrast-enhanced computed tomography. In addition, damage of the roots of the subscapular artery was detected on angiography. Therefore, we placed a polytetrafluoroethylene-covered stent in the axillary artery, including the origin of the subscapular artery. Aspirin and clopidogrel treatment was initiated, stent patency was assessed, and the patient was discharged 25 days after admission. As increased peak systolic velocity was noted on vascular ultrasonography 5 months after the injury, angiography was performed, which indicated 50% stenosis; therefore, we performed percutaneous angioplasty. Until 18 months after the injury, only 25% stenosis was noted. Arterial injury associated with shoulder dislocation rarely occurs, but it could be fatal. However, covered stent placement may be effective in case of surgical difficulty. Moreover, a combination of angiography and vascular ultrasonography is useful for evaluation following stent placement.

View full abstract