Trauma-induced coagulopathy (TIC) is divided into primary coagulopathy caused by trauma itself and secondary coagulopathy, including anemia-, hypothermia-, and acidosis-induced coagulopathy. The main pathophysiology of TIC has long been considered to be disseminated intravascular coagulation (DIC), which is characterized by increased thrombin generation and subsequent consumption coagulopathy due to damage-associated molecular patterns derived from injured cells and tissues. However, trauma surgeons in Europe and the United States of America who express negative opinions about DIC have advocated the activated protein C (APC) hypothesis, which posits that the main pathophysiologies of primary coagulopathy are APC-mediated suppression of coagulation and an APC-mediated increase in fibrinolysis. The APC hypothesis is a highly questionable concept and its pathophysiological theory remains a highly controversial topic. This review summarizes the issues surrounding the TIC controversy and describes the current international consensus, suggesting future directions for readers of this article.

　　A retrospective study was conducted to examine the effects and indications of prehospital resuscitative thoracotomy (pRT).

　　[Materials and methods] Of 121 patients who underwent pRT at our facility between 2012 and 2018, 119 had searchable medical records and met the inclusion criteria for analysis. Outcomes examined included the 24-hour survival rate, survival discharge rate, and rate of Cerebral Performance Category (CPC) 1-2 at discharge.

　　[Results] Of the 119 patients, 116 had blunt trauma and 3 had penetrating trauma. At the time of pRT decision, there were 67 cases of asystole, 31 PEA transfers from the ambulance team, and 21 cases of neck pulse absence after physician contact (NPA). There were 12 cases of 24-hour survival and 7 cases of hospital discharge. At hospital discharge, there were 5 patients with CPC1-2 judged to have a good neurological prognosis, including 3 with blunt trauma. In the comparison among the NPA group, PEA group, and Asys group, there were significant differences in the 24-hour survival rate, survival discharge rate, and discharge rate with CPC1-2. Multiple comparisons of survival and discharge rates demonstrated a significant difference between NPA-PEA and NPA-Asys.

　　[Conclusion] NPA may be a good indication for pRT. Even in Japan where blunt trauma is the main mechanism of injury, pRT may be an option for resuscitative treatment.

　　[Purpose] This study examined the efficacy of bleeding control (B-Con) education among Japanese firefighters. [Method] For this purpose, the “Stop the Bleed” (STB) course for immediate responders (general public) in the United States was implemented among 80 students from the emergency department of a Japanese fire academy ; these students are future professional first responders. We evaluated the participants’ consciousness levels pre- and post-course using a self-evaluation questionnaire with a 10-point Likert scale. [Results] Comparison of the pre- and post-course responses revealed an increase in the scores (2〜4 points) on all questions. Furthermore, self-confidence in educating others significantly increased (P <0.05). [Conclusion] The STB course effectively imparted B-Con education among firefighters. Although regular skill maintenance training is essential, B-Con education needs to be strengthened among firefighters to extend the applicability of the STB course to immediate responders who are part of the pre-hospital trauma care system.

　　Computed tomography (CT) is useful in the evaluation of patients with penetrating neck injuries. However, in patients with critical conditions, CT is impractical and potentially harmful. We present a case of penetrating vertebral artery injury, which was suspected during direct neck exploration and treated by angioembolization under manual direct pressure hemostasis without prior CT. A 55-year-old man sustained a neck injury from a knife. On arrival at the hospital, he was hemodynamically unstable due to active neck hemorrhage. Immediate exploration of the bleeding wound revealed right internal and external jugular vein injuries. Moreover, right vertebral artery injury was strongly suspected. Although the jugular veins were ligated, the vertebral artery hemorrhage was difficult to surgically control. Therefore, we performed angioembolization under manual pressure hemostasis. Angioembolization under manual pressure hemostasis without prior CT may be a treatment option for critical patients with penetrating vertebral artery injuries.

　　A man in his 60s was injured by falling from the bed of a truck and developed bilateral paralysis of the lower extremities. Upon arrival at the hospital, whole-body CT revealed fracture-dislocation of the T11-12 thoracic vertebrae. Vertebral osteophytes of T12 lightly compressed the descending aorta. A REBOA catheter was placed pre-operatively, and the patient was placed in a prone position for dislocation reduction and posterior fusion. Intraoperative hemodynamics were stable and inflation of the REBOA balloon was not required. Spinal surgery in the prone position for thoracic spine fracture-dislocation reduction may lead to life-threatening aortic injury. Prophylactic placement of a REBOA catheter in the proper position with TEVAR standby should be considered as a life-saving measure at the time of surgery.

　　Reports on the usefulness of transcatheter arterial embolization (TAE) for blunt traumatic pulmonary artery injury (BTPAI) are limited. We report a case of BTPAI treated by TAE. An 89-year-old male sustained injuries in a motor vehicle accident and was transferred to our hospital in shock. Chest computed tomography demonstrated a massive left hemothorax with extravasation of contrast media from the peripheral intrapulmonary branch of the pulmonary artery. We performed tracheal intubation, blood transfusion, and TAE of the BTPAI while preparing for emergency thoracotomy. He was extubated on day 18 and transferred to another hospital for rehabilitation on day 62 without rebleeding. TAE for BTPAI is useful and may eliminate the need for thoracotomy.

　　Blunt laryngotracheal injury is a rare type of injury that is potentially life-threatening. Here, we report a case of open blunt laryngotracheal injury due to compression by a helmet strap. A midline incision was made to open the anterior transverse neck wound. Fractured right lamina of the thyroid cartilage and the laryngotracheal injury were observed. An endotracheal tube was intubated via the laryngotracheal injury, and laryngotracheal injury across the vocal cord was confirmed. This case highlights the need for confirmation of an injury and surgical airway management by approaching the midline incision with a high level of suspicion for severe laryngotracheal injury.

　　We report the results of osteomyelitis treatment by free vascularized bone and tissue transfer. Ten patients were eligible for this study. Eight had osteomyelitis of the tibia and one each of the femur and calcaneus. All had several previous surgeries. After debridement of the infected bone, all were treated with free vascularized bone transfer. Multiplanar external fixators were applied for tibial cases. All flaps survived. Nine of them were cured and achieved bone union without infection. One case without negative pressure wound therapy developed infection again due to insufficient debridement and antibiotic-resistant bacteria. Appropriate debridement of infected tissues and treatment with effective antibiotics are crucial to control infection. Negative pressure wound therapy is useful not only for open wounds but also to confirm good granulation after the complete removal of the infected tissue.

　　A 69-year-old man fell from a forklift and sustained fractures of both lower limbs and multiple ribs, which were treated by his previous physicians. The patient was transferred to our hospital on the following day (day 1). Non-occlusive mesenteric ischemia (NOMI) was diagnosed and damage-control surgery (DCS) was performed. Planned re-operation was performed (day 2), and the mesenteric and intestinal circulation was evaluated using intraoperative indocyanine green (ICG) fluorescence. The patient was transferred from the hospital on day 33.

　　An unstable hemodynamic status after severe trauma causes NOMI. However, it is often difficult to determine the degree of intestinal ischemia and the area of necrosis intraoperatively. The combination of DCS and intraoperative ICG fluorescence may be useful to accurately assess intestinal viability, and prevent postoperative suture failure and re-exploratory laparotomy in patients with abdominal trauma.

　　Blunt renal artery injury (BRAI) is rare and its optimal management strategy is unknown. We present a case of bilateral BRAI treated by percutaneous transluminal angioplasty (PTA) and conservative therapy. A male in his 40s was struck by a truck and transferred to our hospital. Contrast-enhanced computed tomography (CECT) and angiography revealed right renal artery disruption, unenhanced right kidney, and an intimal flap in the dorsal branch of the left renal artery, with delayed enhancement in the dorsal part of the right kidney. A stent was placed in the dorsal branch of the left renal artery, but the occluded part of the right renal artery was not passable. As the left kidney was sufficiently preserved by PTA, the right renal artery injury was treated conservatively. Postoperative hypertension was managed by medication. Four months after the injury, the serum creatinine level was 1.12 mg/dl and the stent was patent on CECT.

　　Scapulothoracic dissociation (STD) is a rare entity characterized by shoulder girdle and neurovascular disruption. It is not widely recognized in Japan even though it is a life-threatening injury.

　　We report a case of multiple open fractures of the extremities associated with STD. A woman in her 40s presented with a head injury, multiple open fractures of the extremities, and right subclavian artery and vein disruption after being injured in a traffic accident. The patient underwent subclavian artery and vein ligation for the management of hemorrhagic shock. She received multidisciplinary treatment for multi-organ dysfunction and underwent surgery for fractures ; however, necrosis of the soft tissue of the right hand necessitated amputation of the upper arm. STD may lead to hemorrhagic shock ; physicians should rapidly establish a strategy for hemostasis, evaluate functional disorders, and make decisions regarding limb sparing for earlier recovery of the patient’s condition.