In patients with multiple rib fractures, limited movement accompanied by severe pain prevents improvement in performing activities of daily living (ADL). Multiple rib fractures are often associated with long hospital stays ; therefore, to improve the performance of ADL, it is important to accurately assess the patient’s pain and provide sufficient pain relief. In clinical situations, subjective pain scales, such as the Numerical Rating Scale, are not sufficient for assessing pain to improve the performance of ADL. We developed an alternative pain scale to address this issue. The maximum inspiratory volume of patients can be measured using incentive spirometry (IS). The present study evaluated whether IS values are useful for the objective measurement of pain. Data were collected between 2016 and 2018 from 41 patients with multiple (>2) rib fractures. Patients who received ventilator support and/or exhibited dementia were excluded. Patients demonstrated improvement in performing ADL after receiving pain relief according to our protocol based on the IS value. Rib fractures cause pain during deep breathing ; therefore, the measurement of IS before and after providing pain relief is a useful and objective measurement of pain.

　　Purpose : Although tourniquets are generally indicated for extremity trauma when traumatic amputation or vascular injury is present, it is difficult to assess the presence of vascular injury in pre-hospital care. The aim of this study was to evaluate the criteria for tourniquet use in a doctor helicopter (DH). Methods : Among patients who were transported by a DH and underwent tourniquet application in the emergency department, those on whom tourniquets were not used during DH transportation were divided into hemorrhagic and hemostatic subgroups at the time of arrival. The vital signs obtained in the ambulance were compared between the two subgroups. Patients with trunk injury were excluded. Results : Six of the 12 patients on whom tourniquets were not used during DH transportation were bleeding at the hospital (hemorrhagic group). The shock index (SI) in the ambulance was significantly higher in the hemorrhagic group than in the hemostatic group (SI : 1.40 vs.0.76, p=0.03, cutoff value=1), and vascular injury was observed in all patients in the hemorrhagic group. Conclusion : Patients with extremity trauma and an SI ≥ 1 in the ambulance are likely to have vascular injury, and the use of tourniquets should be considered in DHs.

　　Pancreatic injury is relatively rare and accounts for 5% of blunt abdominal trauma cases. The mortality rate of pancreatic head injury is especially high and there is no established treatment strategy. Pancreatic head injuries are generally associated with multiple trauma and an unstable hemodynamic status ; therefore, operators are required to have high technical skills and damage control strategies are often applied. Post-operative complications are frequent and difficult to control. In this case report, we describe our approach to manage a highly crushed pancreatic head injury in a multiple trauma patient due to a car accident. We avoided damage control surgery, and performed primary pancreaticoduodenectomy and secondary reconstructive surgery. There were no major complications and the patient was discharged ambulatory. Primary pancreaticoduodenectomy for a highly crushed pancreatic head injury may be a good solution when hemorrhage, coagulopathy, and the hemodynamic status are well controlled.

　　Popliteal artery injuries are severe injuries that often result in lower limb amputation if treatment is delayed, and the ischemic condition must be relieved as soon as possible after injury. We report a case in which the limb was rescued using a cross limb vascular shunt (CVS). Application of the CVS was a simple procedure and took 13 minutes. The time from injury to resumption of blood flow was 2 hours and 40 minutes, and revascularization was completed 7 hours and 57 minutes after injury. It is important to understand the indications of CVS and to perform the procedure as soon as possible.

　　A female in her 60s was brought to our emergency department after falling from 11 stories. Contrast CT performed upon arrival to the emergency department revealed hemorrhage from the left lung. We inserted a pulmonary artery balloon into the left pulmonary artery and thoracotomy was performed with pulmonary artery balloon occlusion. Hemorrhage from the left lung was controlled while the pulmonary artery balloon was inflated, and thoracotomy was performed in an operative field with good visualization. For massive hemothorax, adjusting the level of inflation of the pulmonary artery balloon may be useful to resuscitate the patient and to control hemorrhage.