In primary surveys of initial trauma care, unstable pelvic fractures are examined by pelvic X-rays (PXR) in order to detect possible massive extraperitoneal hemorrhages. In some cases, careful reading of the initial PXRs enables the recognition of intrapelvic hematomas (IPH). We examined the diagnostic ability of PXR to detect IPH and the clinical relevancy of IPH in predicting massive hemorrhages. In 116 pelvic fracture cases encountered between 2007 and 2010, PXR diagnosed IPH with a sensitivity of 80% and a specificity of 89%. They were classified into 2 groups according to the presence of extrapelvic hemorrhagic lesions : the pelvic injury-only group (P group) and the multiple-injury group (M group). In the P group, patients with IPH identified by PXR were significantly more likely to develop hemorrhagic shock during initial care (46% vs.10% ; p<0.01) and needed greater amounts of blood components transfused within 24h of hospital presentation than those without IPHs. Because IPH can be successfully diagnosed by PXR and can predict massive hemorrhage caused by fractures in the anterior portion of the pelvis, early identification of IPH by PXR may contribute to reducing “preventable trauma shock” .
Tetanus prophylaxis in adults varies among individuals or institutions in Japan. In this study, we aimed to examine the accuracy of the Tetanus Quick Stick (TQS), which is a rapid tetanus test kit, and to establish a tetanus prophylaxis algorithm for trauma in Japan. In 182 trauma cases brought to our hospital by ambulance from October 2009 to March 2010, we measured tetanus antibody titers (IU/mL) with TQS and enzyme-linked immunosorbent assay (ELISA). We also recorded age, vaccination history, etc. In 114 (62.6%) of 182 cases, the tetanus antibody titer was >0.1 IU/mL, which that is a sufficient protection level against tetanus. The accuracy of TQS was 66.7% sensitivity, 97.1% specificity, and 97.4% positive predictive value. We compared tetanus antibody titers in cases born before and after 1968 when tetanus toxoid was introduced into routine immunization in Japan. As a result, patients with a sufficient antibody titer accounted for 35% of those born before 1967 and over 90% of those born after 1968. We consider that TQS and the difference in the prevalence of tetanus antibody due to age as an important factor for establishing a tetanus prophylaxis algorithm in Japan.
Hemorrhage is the major cause of traumatic cardiopulmonary arrest (TCPA) so, in such cases, massive transfusion should be performed quickly and effectively; however, the method of fluid administration has not been established. Here, we studied the effectiveness of infusion into the right atrial appendage (RAA) in TCPA cases, with reference to RAA cannulation in cardiac surgery. During the study period, data for 20 of 30 TCPA patients (mean age, 47.3 years ; men, 75.0% ; RAA, 10 cases) were collected, and parameters such as infusion volume (total/minute volume), time to start treatment, electrocardiogram (ECG) changes (such as return of spontaneous circulation [ROSC]) for infusion in RAA and the peripheral vein were compared. The infusion volume after RAA cannulation was significantly higher than that in the peripheral vein (p<0.05) ; however, parameters such as time to start treatment, ECG changes, and ROSC between RAA and peripheral vein infusions were not significantly different. Our results suggest that a massive amount of fluid can be infused into the RAA in a short period.
Background : The government has set the traffic fatality target to less than 3,000 by 2015.
Objective : To ascertain problems in Japan's prevention system for traffic fatalities and injuries.
Methods : The rate of head injury for each abbreviated injury score grade (AIS : 1+, 2+, 3+, 4+, 5+, or 6) was compared by seat position using data in the Japan Trauma Data Bank (JTDB). We analyzed registered data for which the seat position in a 4-wheel vehicle during the period January 2005 to December 2009 was clearly recorded.
Results : For JTDB data, AIS scores of 1+, 2+, 3+, and 4+ were higher for the rear seat than for the driver's seat and passenger seat.
Discussion : We can only speculate on the reasons behind these tendencies at this time because Japan has no database which includes both traffic accident and medical status data.
Conclusion : We need to create an integrated database containing data on the both accident and medical status of those involved in traffic accidents to better ascertain prevention measures for Japan.
We evaluated the significance of cold sweat, an important finding for the early detection of shock, in trauma patients. Of 564 trauma patients, 34 (6.0%) were in a cold sweat, 16 of whom required intervention to resolve shock. The injury severity score (ISS) was significantly higher in those in a cold sweat. Of the 564 patients, 59 required intervention to resolve shock. If these 59 patients were regarded as positive, the sensitivity of cold sweat and the shock index (SI) ≥0.82 were 0.27 and 0.83, respectively, and the specificity of cold sweat and SI was 0.96 and 0.72, respectively. Thus, it is difficult to detect shock early based on a cold sweat; however, patients with a cold sweat show an increased severity of trauma. Multivariate analysis revealed that, like SI and a base excess, cold sweat can become a predictor of intervention needed to resolve shock.
In this study, we report the outcomes of surgical treatment in patients with Denis zone III sacral fracture at our center. A consecutive series of 7 patients (average age 38.4 years) with Denis zone III fractures treated surgically over a 5-year period was studied. The cause of injury in all 7 cases was a fall from a height. The average injury severity score was 26.7. Pelvic ring fixation without decompression was performed for all the patients. The time until final follow up was an average of 14.4 months. All the fractures healed eventually. Initial Gibbons classification scores averaged 3.1 and decreased to 1.8. Thus, surgical treatment of Denis zone III sacral fractures was effective ; however, decompression might not be necessary in the acute phase.
An eight-year-old boy with a stab wound to the left lower anterior chest was transported to our hospital 8 hours after the injury. He was hemodynamically stable and was found to have omental herniation from his chest wound. The CT showed left hemopneumothorax and minimal hemoperitoneum. After thoracic tube drainage, surgical repair was performed for the diaphragm and liver and to address bleeding near the stomach, ribs, and pericardium. He was discharged with no complications on postoperative day 19. Children suffer injuries to multiple organs more easily than adults when injured by the same weapon because of their smaller trunk. In this case, we suspected that the abdominal organ injuries had occurred through the diaphragm and were able to repair these organs. In cases of penetrating chest injuries in children with a diaphragmatic injury, abdominal organ injuries should therefore be suspected.
A 44-year-old man arrived at our emergency room after a traffic accident. Computed tomography (CT) showed an unstable pelvic fracture and hematoma with extravasation. We performed angiography, followed by transcatheter arterial embolization of the bilateral internal iliac arteries. Oliguria subsequently appeared. CT showed bilateral hydroureteronephrosis, caused by hematoma from the pelvic fracture. We inserted a balloon catheter deeper into the bladder, allowing urine flow through the left ureter and thus avoiding post-renal acute kidney injury. Bilateral hydroureteronephrosis subsequently improved with the disappearance of the hematoma. Drainage by nephrostomy and hematoma removal have been reported, but it may be effective to change the position of the balloon catheter tip if it be performed safety.
A 68 year-old man developed meningitis of unknown origin in November, 2007. It was cured once, but left cerebrospinal otorrhea appeared in August, 2009 and continued afterwards. Because it was accompanied by left exudativa inflammation of the middle ear and excessive nasal mucus, he was referred to the Department of Neurosurgery in May, 2010. CT revealed a small bone deficit of the frontal base of the skull, which was thought to be the cause of rhinorrhea. He was hospitalized and underwent surgery. In the operative view, we found a fracture with a deficit of the dura mater covering from the left superior wall of the orbit to the frontal base of the skull. There has been no recurrence. After the operation we discovered that more than 40 years earlier he had suffered a head injury during wrestling practice at college ; however, he had experienced no symptoms until now. A relationship with cerebrospinal fluid leakage was suggested.
In trauma therapy, conservative treatment has become the mainstream, and no adequate surgical education is available to residents who want to be a trauma surgeon. Some countries hold training courses using human cadavers or animals for simulation surgery ; however, there is no such trauma surgical training course in Japan. We held a seminar on educational study in which we discussed trauma surgery using a human cadaver. Twelve medical doctors participated in the seminar, which was held in the anatomical practice room of Tokyo Medical University as a one-day program, focusing on vascular, thoracic and abdominal injury. We administered a questionnaire about surgical skill before and after the seminar. All participants answered that the seminar had been very useful for trauma management, and all participants other than junior residents answered that they might perform a surgical procedure, even if they had not experienced it before. Seminars using a human cadaver are effective for trauma surgery education.
We have to encourage cooperation with the Department of Anatomy, take action to authorize this type of seminar and combine with seminars using animals to maintain and develop this trauma seminar.