Introduction : Traumatic brain injury (TBI) is reported to cause cerebral circulation disturbance. Ischemia is one of the major risk factors contributing to death and disability. The purpose of this study was to evaluate cerebral circulation in different types of severe TBI. Methods : Ninety patients with severe TBI were divided into five groups, the subdural hematoma group, the epidural hematoma group, the contusion/intracerebral hematoma group, the diffuse axonal injury group, and the diffuse brain swelling group. In these patients, we simultaneously performed Xe-CT and perfusion CT to evaluate the cerebral circulation on post-injury days 1-3. We measured CBF using Xe-CT and mean transit time using perfusion CT, and calculated the cerebral blood volume. Results : The patients who had focal TBI exhibited more significant cerebral circulation disturbances than those that had diffuse TBI. Analysis of variance demonstrated significant differences in CBF and MTT. The CBF values of patients with SDH were the lowest of the 5 groups and the MTT values of patients with SDH were the highest. Conclusion : We demonstrated that there were differences in cerebral circulation among different intracranial pathological conditions. All possible treatment measures, including hypothermia therapy, should be performed based on pathological conditions.
A man in his 40's collided with a truck while drink-driving. After approximately 24 hours, he visited a nearby hospital and was diagnosed with right hemopneumothorax, pulmonary contusion, and multiple right rib fractures from the 1st to 10th levels. The patient was then transferred to our hospital. His clinical condition was relatively stable until the 3rd day of hospitalization, when he suddenly developed sepsis and acute respiratory distress syndrome, for which he was admitted to the ICU. Repeated blood cultures demonstrated the presence of methicillin-sensitive Staphylococcus aureus. Follow-up enhanced CT on the 21st day of hospitalization exhibited multiple chest wall abscesses around each rib fracture. The blood cultures became negative after drainage was performed. He was discharged on the 126th day of hospitalization. This is a rare case of closed blunt chest trauma with multiple chest wall abscesses. The importance of early antimicrobial therapy for severe blunt chest trauma is suggested.
A 35-year-old woman was injured while riding her bicycle and presented to our department. We performed perihepatic packing based on a diagnosis of hemorrhagic shock with hepatic injury type III b, and performed interventional radiology after surgery. There was extravasation from the right hepatic artery (RHA), which branched from the superior mesenteric artery. We attempted transcatheter arterial embolization (TAE), but it was difficult because the branching angle had markedly changed with abdominal compartment syndrome. We therefore performed RHA ligation with laparotomy and achieved successful hemostasis. The patient was discharged without complications, in contrast to the predicted survival rate of 27.6%. Right hepatic artery ligation is considered an effective surgical procedure for damage control in cases of uncontrolled hemorrhage when TAE is impossible.
Although chest compression is an effective emergency maneuver for cardiopulmonary arrest (CPA), it carries a risk of complications such as rib fracture, sternal fracture, and organ injury. Two cases of CPA due to pulmonary thromboembolism were admitted to our department. Spontaneous circulation was restored with cardiopulmonary resuscitation (CPR) including chest compression. After use of an anticoagulant drug and indication of veno-arterial extra corporeal membrane oxygenation, contrast-enhanced computed tomography demonstrated infra-diaphragmatic liver injury in both cases. One patient could survive with damage control surgery (DCS), while the other patient could not survive without surgical management. As a conclusion, patients with hemorrhagic diathesis are at critical risk for complications from chest compression. Aggressive treatments, including DCS, may be effective even for patients treated with anticoagulant drugs.
A 66-year-old woman was admitted to our hospital with right chest pain without any memory of trauma. Vital signs were tachypneic, tachycardic (112/min), normotensive (119/84mmHg) and normothermic (36.1 degrees centigrade). Chest contrast-enhanced CT demonstrated a large hemothorax with fractures of ribs 11 and 12. Active bleeding from the right inferior phrenic artery originating from the right renal artery was observed on angiography. The right inferior phrenic artery was embolized using N-butyl-2-cyanoacrylate mixed with Lipiodol. In conclusion, an injured right inferior phrenic artery originating from the abdomen can be a cause of hemothorax.
An 82-year-old woman was brought to a local hospital due to an abdominal stab wound. Intraabdominal hemorrhage was controlled with intraabdominal packing, and the patient was referred to our hospital for further treatment. At re-operation, infrahepatic vena caval injury was confirmed and repaired. Postoperative course was complicated by deep venous thrombosis of the lower limbs, but the patient recovered and was transferred to a local hospital on postoperative day 19. Packing may be an option for selected cases of penetrating inferior vena caval injury without concomitant injuries.
A 39-year-old male sustained open left knee joint fracture with 8cm bone defect and 12×15cm soft-tissue loss after ａ car accident. Thirteen days post-injury, reconstruction with ａ free flap was performed. Unfortunately, it failed due to venous embolism. Twenty-one days post-injury, below-knee amputation was performed using ａ long posterior tibial artery flap. The flap with the distal part of tibia was flipped upside-down and fixed to the proximal tibia, covering the soft tissue defect completely. Three months later, knee function and residual limb length was preserved, and the patient was ambulating well with ａ below-knee prosthesis. One of the major benefits of spare parts surgery is when there is not enough local tissue to perform below-knee-amputation, the flap can supply extra tissue and may prevent above-knee-amputation. We encourage the use of spare parts surgery in amputation following extensive extremity trauma.
A woman in her forties was brought to our critical care center in shock after a 3-story fall. Blunt force trauma was observed on the anterior aspect of the thorax and a FAST exam revealed fluid collection only in the left thoracic cavity. Contrast-enhanced computed tomography demonstrated multiple facial fractures, a pneumomediastinum, left hemopneumothorax and pulmonary contusion, right hepatic injury and a left ischiopubic fracture. During transarterial embolization for post-traumatic extravasation from the bilateral hepatic and external carotid arteries, continuous evacuation of blood was observed from the left thoracostomy tube, and therefore, an emergency left lateral thoracotomy was performed, whereby an active hemorrhage from the pulmonary contusion was identified and partially resected. Further bleeding from the dorsal aspect of the heart was noted and subsequently diagnosed as a rupture of the left atrial roof complicated by pericardial injury. Hemostasis was achieved using a pericardial patch and surgical sealant to seal off the transverse pericardial sinus, which ultimately saved the patient's life. The post-operative course was uneventful and the patient was stabilized and transferred to another hospital 61 days postoperatively. The method described in this report is an effective treatment option in cases such as this where the use of heart-lung machines is considerably restricted.
Having had the opportunity to talk to the parties involved in the London subway bomb attacks in July 2005, the lessons learnt are reviewed. While the initial responses of those interviewed followed the format of the Major Incident Medical Management and Support (MIMMS) system, someproblems became apparent. From viewpoints of traumatology, the blast injuries attracted medical attention after the attack, the introduction of tourniquets to the attacked field was introduced after the Boston Marathon Bombing (2013) and the Paris Attack (2015). We should prepare the unforeseen attacks at the time of Tokyo Olympic/Paralympic 2020 as an international responsibility.
Based on the report by Assistance Publique-Hôpitaux de Paris (APHP) and Service d'Aide Medicale Urgente (SAMU), the emergency medical response to the multisite terrorist attacks by shooting and bombing in Paris in November, 2015 was demonstrated. France has the pre-, in-, and inter-hospital response plan for mass casualty incident. Aggressive use of tourniquet and gauze containing hemostatic agent, restricted fluid resuscitation with vasoconstrictor and tranexamic acid, and avoid hypothermia are the key elements of prehospital treatment in multiple shooting or bombing. Additionally direct transfer system for victims from scene to operating room has been planned. In this incident, there were 129 dead on scene. The 356 victims with "isolated chest injury" or "abdominal and/or limb wound" were categorized as "Absolute Emergency" and transferred to 18 pre-planned hospitals in the form as a package with 5-8 patients to one hospital at one time. In Pitié Salpêtrière University Hospital, 23 of 53 victims were received damage control surgery in 10 of 13 operating rooms (OR) at most without saturation. The mortality at the 7th day of 16 APHP hospitals was 1.3%. This information emphasizes the importance of rapid and adequate prehospital treatment, pre-planned referral hospital network, and sequential group transfer system and surge capacity of OR.