[Background] In elderly severe-trauma patients, physiological abnormality is not easily identified during primary examination. Cases of mortality due to delayed diagnosis of bleeding site have been reported. The purpose of this study was to compare massive bleeding sites in younger and elderly severe trauma patients. [Material and Methods] We retro­spectively reviewed a total of 76 cases of massive bleeding that were admitted to our institution between September 2006 and December 2013. Massive bleeding was defined as bleeding requiring transfusion of red cell concentrates of more than 10 units within 24 hours after admission or as early death due to massive bleeding. [Result] There were 35 younger patients and 41 older one. The proportions of non-diagnosable cases in primary surveys (massive bleeding due to multiple-site damage caused by a bone fracture and contusion, retroperitoneal hematoma without a pelvic ring fracture and with a stable pelvic ring fracture) were 16% in younger patients and 39% in older patients, with a significant difference between them (P<0.05). [Conclusion] Even if no abnormality is observed during the primary survey in elderly severe-trauma patients, massive bleeding should be considered and treated immediately once diagnosis is confirmed.

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　　The purpose of our study was to analyze the risk factors for complications in patients with pelvic fractures undergoing transcatheter arterial embolization (TAE). We enrolled 80 patients with pelvic fracture transferred to our hospital in this study, among whom 52 underwent TAE. TAE of the internal iliac artery was performed unilaterally in 7 patients and bilaterally in 45 patients. Complications were observed in 5 patients : 2 patients developed gluteal muscle necrosis and 3 developed gluteal or genital skin ulcer. The complication rate among all patients undergoing TAE was 9.6% (5/52 patients). The complication rates for unilateral and bilateral internal iliac artery embolization were 0% (0/7 patients) and 11.1% (5/45 patients), respectively. No complications were observed in patients who underwent unilateral embolization. In patients in whom soft tissue evaluation was performed using enhanced CT, subcutaneous hematoma was observed in 4/5 patients (80%) who experienced complications and in 2/2 patients (100%) with necrosis. Our results suggest that attention should be paid to complications in patients who undergo bilateral internal iliac artery embolization, particularly in those with subcutaneous hematoma.

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　　To improve the quality of prehospital care in trauma cases, the Medical Control Council of Southern Higashi-Katsushika (containing the cities of Ichikawa, Urayasu, Kamagaya, Narashino, Funabashi, and Yachiyo) in Chiba Prefecture established an emergency service verification system for trauma in 2011. After responding to a severe trauma case, paramedics file a report in the system, which is evaluated by the person in charge of the city's fire department and by the doctor in charge of a regional emergency hospital. In 2011, analysis of system data revealed that the emergency response times of the para­medics of Fire Department A were notably longer than those of paramedics in other cities. Investigation of the causes and improvement of the problems significantly reduced the emergency response times in 2012. This shows that data of the emergency service verification system for trauma can be used for statistical analysis of severe trauma cases in this dregion, which has a population of 1.7 million people. However, to take full advantage of the system, it is important to perform prompt and consistent verification of trauma cases, use the data to instruct paramedics, and promote cooperation between emergency hospitals within and outside the district.

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　　A 25-year-old male was involved in a traffic accident while riding a motorcycle. He was transferred to our hospital and was diagnosed with blunt liver injury and pulmonary contusion. Abdominal angiography showed liver injury on the right lobe with arterioportal (AP) fistula, and emergency transarterial embolization (TAE) was performed for the posterior branch of the hepatic artery using absorbable gelatin sponge. Although repeated TAE (three times in total ; on admission, day 9, and day 16) was performed, AP fistula was still present on hospital discharge. Follow-up abdominal computed tomography (CT) at 14 months after injury showed that the AP fistula had disappeared. In this case, conservative management and TAE were effective to solve the blunt liver injury with AP fistula.

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　　We report a case of fetal survival from a brain-dead mother at 25 weeks' gestation with serious injury from a car accident. She suffered severe hemo-pneumothorax, liver contusion, and right femur fracture without brain injury. She became brain dead due to severe brain swelling with an unknown cause on day 7. Her family agreed to save the fetus on day11. A 718g male infant was delivered by a cesarean operation. Half a day later, the patient's heart stopped beating. Four months later, the baby was discharged in a healthy condition.

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　　A 45-year-old woman consulted us for a bruise on her abdomen caused by a bicycle seat. On arrival, the patient was alert, with stable vital signs, and mild abdominal pain and tenderness. Abdominal CT revealed a type III pancreatic injury in the pancreatic head and intraperitoneal bleeding. Damage to the main pancreatic duct was suspected ; however, definitive diagnosis was difficult using the CT findings alone. She was kept under close observation, but no additional examinations were performed because the patient had only mild abdominal symptoms and stable vital signs. Her vital signs remained stable and there were no further abdominal symptoms. Abdominal CT performed two weeks later revealed a cyst in the pancreatic head and biliary duct dilatation, which were successfully treated by percutaneous pancreatic cyst drainage. We report a case of pancreatic injury with suspected damage to the main pancreatic duct that resolved with strict observation and conservative treatment.

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　　A 69-year-old female suffered a fall in her home, and was consequently admitted with traumatic subarachnoid hemorrhage, left chest pneumoderma, left hemopneumothorax, left clavicle fracture, and left flail chest, including fractures of left 2nd to 10th ribs. Surgical fixations of the left ribs and clavicle were performed 8 days after admission because of the marked displacement of the 3rd rib segment into the thoracic cavity. Ventilator use was discontinued 1 day after the operation ; however, the subsequent respiratory function remained stable.
　　Because the surgical procedure using a rib fixation plate could be performed without the need for drills or screws, or thoracotomy, it is a technically safe method. Surgical fixation for flail chest with rib plates is thought to be a promising treatment, with early ventilator weaning.

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