Whole-body computed tomography (WBCT) has been promoted for the management of blunt trauma (BT) in high-income countries. Japan advanced trauma evaluation and care (JATEC) guidelines recently allowed not only head but also WBCT for patients with life-threatening, central nervous dysfunction at the beginning of a secondary survey. We conducted this nationwide study to verify that JATEC statement. Japan Trauma Data Bank data (2007-2010) were used for comatose BT patients with systolic blood pressure>75mmHg. As probability of survival (Ps) by the Trauma and Injury Severity Score (TRISS) method was uesd for severity adjustment, 2,973 patients were analyzed without missing variables necessary for TRISS Ps calculation. WBCT was defined as CT including the head, neck, chest, abdomen, and pelvis during initial trauma management, and compared the WBCT group with patients without one or more CT of the body regions (non-WBCT). No significant difference in TRISS Ps was observed between the groups. However, the recorded mortality proportion was significantly lower (p<0.0001) in the WBCT group (0.34 [95% CI : 0.31-0.37]) than in the non-WBCT group (0.42, [0.39-0.44]). In Japan, integration of WBCT into initial trauma management may decrease mortality in comatose BT patients indicated for head CT.
Objective : To clarify the clinical features and current treatment protocols of idiopathic pneumomediastinum.
Subjects : The clinical features of 75 patients were studied, 4 patients at our hospital and 71 patients over the past 5 years who could be searched in the Japan Medical Abstracts Society database. The mean age, BMI, male-to-female ratio, contributing factors, distribution of initial symptoms, treatment duration, and proportion who were administered antimicrobial therapy were studied retrospectively.
Results : The mean age was 20.8 years, mean BMI 19.5, and male-to-female ratio 52 : 23. The most common contributing factor was no specific factor (51%), followed by exercise (25%). The initial symptoms were pleural friction rub (62%), chest pain (60%), and pharyngeal pain (36%). The number of inpatients was 57 (76%), the mean hospitalization duration was 6.9 days, the number of outpatients was 18 (24%), and the proportion of patients who were administered antimicrobial therapy was 46%.
Conclusion : Idiopathic pneumomediastinum is a relatively uncommon condition and tends to occur in younger men with low BMI, without specific contributing factors and displaying symptoms of chest pain and pleural friction rub. Hospitalization was required for 76% of patients and antimicrobial therapy was administered to 46% of patients.
We retrospectively investigated our clinical performances and trauma outcomes before and after the institution of the Japan Advanced Trauma Evaluation and Care (JATEC) program.
There were 198 patients before JATEC and 297 patients after JATEC. Overall mortality decreased and minor and moderate severity (ISS≦24) mortalities significantly decreased post-JATEC. No difference was identified in modified unexpected mortality (n=8, 36.4% vs. n=5, 29.4%). Among severe trauma patients (ISS≧25), there was no difference in mortality without resuscitative intervention before versus after the JATEC program, but mortality with resuscitative intervention tended to decrease after versus before the JATEC program. There was no difference in the time to initiate resuscitative intervention.
There is still room for improvement of our clinical system for severe trauma patients.
There are several reports of the rupture of pseudoaneurysms of the superior or inferior gluteal artery with massive bleeding occurring during internal fixation of pelvic fractures that required suspension of the operation to perform emergency transcatheter arterial embolization (TAE) of the pseudoaneurysm. Therefore, in our institution, internal iliac angiography is performed before internal fixation of pelvic fractures, and when a pseudoaneurysm is discovered, it is treated by TAE.
Since April 2007, internal iliac angiography has been performed on 17 patients before internal fixation of their pelvic ring fractures. TAE was performed on 3 patients with a superior or inferior gluteal artery pseudoaneurysm. Thereafter, internal fixation of the pelvic fractures was finished without acute massive bleeding.
In cases of internal fixation of pelvic ring fractures, angiography needs to be performed first, and when a pseudoaneurysm is present, it needs to be treated by TAE so that the internal fixation can be completed safely.
Autologous blood patch has been considered as a useful treatment for consistent pleuropulmonary air leak following lung surgery. In this report, we describe two cases of post-traumatic persistent pneumothorax treated by an autologous blood patch. The first case was a 50-year-old man who suffered a traumatic right pneumothorax in a traffic accident. Since he had severe pulmonary emphysema as a comorbidity, an autologous blood patch was applied as the initial treatment, which resulted in a satisfactory clinical outcome. The second case was a 22-year-old man who suffered a traumatic left pneumothorax in a traffic accident. He was also successfully treated by an autologous blood patch. Autologous blood patch is the treatment of choice for post-traumatic persistent pneumothorax.
Introduction : Cryoprecipitate is a blood product produced from concentrated fresh frozen plasma (FFP) and promotes hemostasis in massive bleeding. Case : A 76-year-old man driving an automobile collided with a truck. The patient had bilateral costal fractures, hemopneumothorax, traumatic aortic dissection (Stanford B), and a right femoral fracture. No sites allowed surgical hemostasis, and shock was observed from bleeding into the subcutaneous and soft tissues at multiple sites. Due to unstable circulation and persistent low fibrinogen, despite massive FFP administration, three packs of cryoprecipitate were administered. After administration, transfusion volume decreased, and the patient was transferred for further rehabilitation on hospital day 59. Discussion : Patients with low fibrinogen are predisposed to hemorrhage, complicating hemostasis. Administration of cryo apparently promoted hemostasis in this case. Conclusion : Administration of cryoprecipitate was useful in a case of multiple traumas with a low fibrinogen level.
We report the case of a 5-year-old child with traumatic asphyxia after being trapped by a tractor. At the time of rescue, he had periorbital ecchymosis and ecchymoses over the upper thorax. On admission, his Glasgow Coma Scale score was 5 (E1V2M2). Tracheal intubation was performed immediately, followed by mechanical ventilation. Normothermia was maintained and glycerol was administered to prevent brain edema. Although the patient was unconsciousness for a day, he recovered with no evidence of cerebral injury. He experienced double vision for 10 days, but his clinical course was otherwise favorable. Loss of consciousness and neurological impairment including visual disturbance may occur in cases of traumatic asphyxia. Although patients usually recover consciousness, visual disturbance may persist. Treatment to avoid visual disturbance is as important as treatment for cerebral protection.