We retrospectively examined pelvic fracture patients who were transported to our emergency medical center between January 2016 and December 2018. One hundred and twenty-four patients with pelvic fractures, stable vital signs and no contrast extravasation on enhanced CT were enrolled. The TAE group included 11 patients and the non-TAE group included 113 patients. There were significant differences between the two groups in ISS (p<0.001) and D-dimer level (p=0.034). Based on multivariate analysis, ISS significantly increases the risk. In patients with pelvic fractures associated with severe trauma (ISS> 24), angiography should be considered even if the vital signs are stable and no contrast extravasation is observed on contrast-enhanced CT.

　　Meckel’s diverticulum (MD) is a congenital anomaly. Most cases are clinically silent, but some exhibit hemorrhage and inflammation. We treated a patient with perforated MD caused by blunt trauma, which is rare. The patient was a 52-year-old man who was injured while riding a motorbike, and developed pain in the left leg and abdomen. His vital signs were stable, and physical examination revealed contusions on his right chest, left lateral abdomen, and fingers, and left leg swelling. Enhanced computed tomography demonstrated slight free air and ascites. As ascites production continued to increase, emergency surgery was performed. The ascites included blood and enteric contents. Perforation of MD was identified 40 cm from the ileocecal junction, with mesenteric contusions. MD was resected, and his clinical course was normal. Histopathological examination of the specimen revealed no heterotopic epithelium.

　　A 57-year-old woman sustained maxillofacial trauma from a falling shutter. On arrival at the hospital, she presented with hemorrhage from the oronasal cavity. She was in semicoma (Glasgow Coma Scale E1V2M5), but other vital signs were stable. We performed rapid intubation. Computed tomography (CT) revealed multiple maxillofacial and axial dislocation fractures. The patient did not have any other signs of injury. After CT, although we applied oronasal packing, hemorrhage from the oronasal cavities increased. Angiography revealed contrast medium extravasation from the bilateral external carotid artery. We therefore performed transcatheter arterial embolization (TAE) of the external carotid artery. The postoperative course was uneventful, and the patient was discharged on the 34th hospital day. Maxillofacial trauma can cause fatal airway obstruction, respiratory disorder, and life-threatening hemorrhage from the oronasal cavities. Emergency TAE is effective for massive traumatic oronasal hemorrhage that cannot be controlled by packing and exhibits extravasation on contrast-enhanced CT.

　　The patient was a woman in her 60s who went into cardiopulmonary arrest due to food asphyxiation. After the return of spontaneous circulation following removal of a foreign body from her airway and compression of the sternum, the patient was brought to our hospital. Examination after arrival revealed injuries to the ascending pharyngeal artery and liver, both requiring treatment by transcatheter arterial embolization (TAE). Although TAE is a useful hemostatic method in trauma care, some embolic agents should be avoided depending on the target artery for embolization. For this reason, performing TAE requires appropriate knowledge.

　　A man in his forties was injured in a traffic accident. Chest CT demonstrated fracture of the third and fourth ribs on the left side, with pulmonary tissue protruding through the thoracic cage. He was diagnosed with traumatic lung herniation. We resected the damaged lung tissue, fixed the rib cage, and reconstructed the chest wall using the serratus anterior muscle. We report a case of lung hernia as a rare finding.

　　A 74-year-old man was brought to our center with a self-inflicted penetrating stab wound on the left side of his neck. As marked external hemorrhage was present in Zone II of his neck on arrival, we performed temporary hemostasis for the neck stab wound and operated again on day 2. However, he developed cerebellar symptoms following the surgery and imaging studies revealed cerebellar infarction. A fragment of the knife was left between C5 and C6, which had damaged the left vertebral artery and induced cerebellar infarction. As the location of the fragment was anatomically challenging and removal may have caused uncontrollable hemorrhage, we performed conservative treatment. He was discharged on day 58 without complications such as rebleeding, pseudoaneurysm, and infection. Patients with Zone II penetrating neck injury should be evaluated for vertebral artery injury by CT and angiography confirming the entire trajectory of the object.

　　A 38-year-old man crashed his car into a utility pole and was brought to our hospital. His breathing and circulation were stabilized, but his right arm demonstrated marked hyperesthesia and monoplegia. There were no indications of cervical fracture on computed tomography. On day 2, suspicion of brachial plexus injury prompted magnetic resonance imaging (MRI), which revealed a hematoma in a mosaic pattern in the right dorsal column of the spinal cord from C3 to C6 on T2-weighted images. Based on the symptoms and imaging findings, we diagnosed him with cervical epidural hematoma. His monoplegia improved over time and we adopted conservative treatment. MRI on day 7 revealed recession of the hematoma. His monoplegia improved and he was discharged on day 9. In the case of palsy in a single upper limb associated with trauma, cervical epidural hematoma must be considered and detailed examination is required.

　　Arterial embolism due to back trauma is rare. A 54-year-old male was transferred to our hospital because of bilateral lower limb paralysis and sensory disturbance following blunt trauma to his back. Trauma was sustained by a shutter falling from two meters above and striking his lower back. On arrival, he presented with bruising on his lower back, sensory disturbance, and palsy in his right leg and left ankle. His right dorsalis pedis artery and posterior tibial artery were not palpable. Computed-tomography angiography demonstrated right popliteal artery occlusion and marked atherosclerosis of the abdominal aorta. Thrombectomy for popliteal artery occlusion was performed, but necrosis progressed, necessitating below-knee amputation. Although spinal cord injury or ischemia after lower back trauma is a likely cause of lower limb paralysis, earlier diagnosis and treatment of concurrent acute arterial embolism from aortic atherosclerosis may lead to successful leg salvage.

　　A 42-year-old woman injured in a traffic accident was transferred to our hospital. Computed tomography (CT) demonstrated multiple rib fractures, including the right first rib, right hemopneumothorax, and spleen and left kidney injury. On hospital day 2, she developed circulatory collapse and cardiac arrest. Cardiopulmonary resuscitation resulted in return of spontaneous circulation. Contrast CT revealed massive right hemothorax and extravasation from a right subclavian vein (SCV) varicosity. To control the massive hemorrhage, we exposed and removed the right clavicle diaphysis, which enabled us to access the SCV and obtain hemostasis. She was discharged on hospital day 60 with no neurological deficit and full range of motion of her shoulder. Supraclavicular incision and resection of the clavicle diaphysis may be a useful method to expose an injured SCV to obtain hemostasis.

　　A male in his 70s with a history of gastrostomy collided with a utility pole while driving a car. Contrast computed tomography revealed splenic injury with hemorrhage, several rib fractures on the left side, and a left humeral fracture. Gastrostomy injury was unclear. Emergency transcatheter arterial embolization (TAE) was performed and hemostasis was achieved. After TAE, free air developed in the abdominal cavity. Gastrostomy injury was diagnosed and operative management was initiated. The entire spleen was resected and gastrostomy was newly constructed. The postoperative clinical course was good and the patient was discharged 22 days after surgery. It is important to assume gastrostomy injury when examining a patient with blunt trauma and a history of gastrostomy.

　　Objective : To evaluate the indications, safety, and effectiveness of extracorporeal membrane oxygenation (ECMO) performed immediately after injury. Methods : Medical records of patients who underwent ECMO on the day of injury over a 10-year period were retrospectively reviewed. Results : Four males with a median age of 28.5 years, median injury severity score of 41, and median survival probability of 0.734 were enrolled. Three patients sustained blunt trauma and one sustained penetrating trauma. Indications included respiratory failure caused by airway hemorrhage due to bilateral lung injury in three patients and refractory ventricular fibrillation with hypothermia in one. The median duration between injury and the start of ECMO was 3 h. Two patients underwent venovenous ECMO and the other two underwent venoarterial ECMO. None of the patients received initial anticoagulation therapy. All patients exhibited improvement in acidosis immediately after ECMO. The body temperature increased quickly in one patient with hypothermia. No direct complications of ECMO were observed. Two patients survived. Conclusions : Anticoagulation therapy is not necessarily needed when ECMO is initiated. Regarding the trauma triad of death, acidosis can be improved, whereas hypothermia may be corrected. ECMO immediately after injury can be a treatment option for respiratory failure due to severe lung injury and cardiac failure.

　　We report a rare case of spontaneous lateral abdominal hematoma. A 61-year-old man presented with the sudden onset of severe pain from the left hypochondriac region to the left lateral abdominal region after coughing followed by dizziness. He was transferred to the emergency room and was in the shock vital status upon arrival. Induration in the left lateral abdominal wall was detected. Computed tomography revealed spontaneous hematoma in the left abdominal oblique muscles. Conservative treatment with intravenous fluid resuscitation was administered because of the lack of contrast medium extravasation, which stabilized his vital signs.

　　Portal venous gas (PVG) and pneumatosis intestinalis (PI) are considered rare findings, and are associated with a poor prognosis. The most common underlying pathology is bowel necrosis. Cases of PVG and PI due to trauma have been reported ; however, the delayed appearance of PVG and PI in a blunt trauma patient has yet to be reported. The patient was a man in his 70s who had been hit by a car. As consciousness disturbance and shock were observed at the scene, he was transported to our hospital. He sustained traumatic brain injury. Conservative management was initiated and his consciousness level improved. However, his vital signs became unstable on hospital day 4 and CT was performed, which revealed PVG and PI. Emergency laparotomy, which was performed for suspected bowel necrosis, revealed no bowel necrosis. Postoperative management included broad-spectrum antibiotics and polymyxin B-immobilized fiber column direct hemoperfusion. The postoperative course was uneventful. The patient was transferred to another hospital on hospital day 41.

　　Control of hemorrhage and precise evaluation of the bowel circulation is required for patients with mesenteric injury. We evaluated the efficacy of intra-operative indocyanine green (ICG) fluorography for indicating bowel resection in a patient with mesenteric injury. A 75-year-old man was injured in an automobile accident and had intra-abdominal hemorrhage with severe shock. Laparotomy was performed on a resuscitation table. Hemostasis of the mesenteric vessels in the small intestine was achieved and damage control surgery was performed. We performed a second-look operation 24 h later. The small intestine was preserved because no intestinal ischemia was confirmed under ICG fluorography. ICG fluorography of the intestine to assess the bowel circulation during a second-look operation is effective for patients with mesenteric injuries.

　　Spinal immobilization during the pre-hospital phase of trauma management has been the standard practice for patients with suspected spinal injury. The purpose of immobilization in suspected spinal injury is to maintain a neutral position, and avoid displacement and secondary neurological injury. However, complications associated with prolonged patient immobilization on the backboard have been reported. Considering the circumstances of secondary emergency care center and these complications, trauma patients should not remain on backboards until their spinal injuries can be radiographically assessed. While being careful not to exacerbate potential spinal injury, it is recommended to remove all patients from the backboard as soon as possible in the emergency department. It is the most effective to remove backboards with the cooperation of doctors, nurses and EMS providers, for which in-hospital training is necessary.