Delayed Hemorrhage of the Hepatic Artery Caused by Biliary Stenting after Concurrent Chemoradiotherapy

Neoadjuvant concurrent chemoradiotherapy has been increasingly used to obtain secondary resectability for locally advanced pancreatic cancers. Although most patients require biliary decompression, only a few studies have investigated the safety of biliary stenting with chemoradiotherapy. Herein, we report a rare case of delayed hemorrhage of the hepatic artery caused by biliary stenting after chemoradiotherapy. The serial follow-up CT demonstrated that the biliary stent was approaching the right hepatic artery and eventually caused acute angulation and indentation. Diagnostic catheter angiography revealed contrast extravasation at the right hepatic artery, and endovascular embolization was performed. This report highlights the relevance of anatomical deformation after chemoradiotherapy, which can result in fatal complications. Indentation of the hepatic artery caused by biliary stents should be recognized as a warning sign of vascular injury.

Equipment for Difficult Airways in 67 Korean Academic Emergency Departments

PURPOSE: In Korea, there has been no research about the devices that are used for dealing with difficult airways in emergency departments (ED). This study reports the results of the first research of this kind, assessing the equipment in Korean EDs that is used to manage patients with difficult airways. METHODS: We surveyed 92 EDs via the Internet from October 2007 to March 2008. All respondents were asked if they have the following categories of devices in their EDs; alternative intubation devices, alternative rescue ventilation devices, and surgical airway devices. Alternative intubation devices were defined as devices that do not use a direct laryngoscope for tracheal tube insertion. Alternative rescue ventilation devices were defined as ventilation devices that do not use a face mask. Surgical airway devices were defined as devices that use a surgical technique for the placement of endotracheal tube. RESULTS: We obtained data from 67 of the 92 (72.8%) EDs we contacted. Of those, 32 (47.8%) EDs have at least one alternative intubation device, 52 (77.6%) EDs have at least one alternative rescue ventilation device, and 59 (88.1%) EDs have at least one surgical airway device. A total of 30 (44.8%) EDs have equipment in all 3 categories, but 4 (6.0%) EDs do not have any equipment for dealing with difficult airways. The most common alternative intubation device was a flexible fiberscope (29.9%). CONCLUSION: The possession of devices to deal with difficult airways varies across EDs. It seems that not all Korean EDs have enough devices for difficult airways.

What time do you have?

PURPOSE: In the emergency medical field, a small error of time can make a huge difference because many difficult decisions depend on time. The purpose of this study was to confirm errors on the timepieces used by the medical system and to emphasize the importance of accurate time. METHODS: The timepieces of physicians, nurses, firefighters, paramedics, emergency department wall clocks, order communication system (OCS) computers, defibrillators, ECG machines, patient monitoring devices were investigated in 5 emergency medical centers. The time in OCS main server and 1339 emergency medical information center were checked by phone. The time on each timepieces was compared with the time of coordinated universal time korea (UTCK). The types of timepieces were confirmed and how often they set the time. RESULTS: There were 203 timepieces in 236 subjects. The timepieces had a mean error of 12 minutes 14 seconds. The errors were smaller in timepieces worn by the personnels compared to time on various devices used in the emergency department. The maximum error, 16 hours 20 minutes 31 seconds was found on patient monitoring devices. CONCLUSION: The timepieces used in the emergency medical care are often inaccurate. This can create medical or medicolegal problems. We should recognize the importance of maintaining accurate time and put an effort in reducing the errors of our timepieces.

Cervicofacial Subcutaneous Emphysema and Pneumomediastinum after a Dental Procedure

The occurrences of subcutaneous emphysema or pneumomediastinum after a dental procedure are rare, but they are potentially life-threatening complications. These complications are reported to occur mainly in patients after dental procedures on the third molar, in particular during mandibular extractions and treatment on the right side. A 22-yearold woman visited the emergency department with neck swelling and chest pain after a right lower third molar extraction. She had a subcutaneous emphysema on the face and neck. Her chest x-ray and computed tomography of the chest showed a pneumomediastinum. She was discharged 6 days later without serious complications. Many cases of subcutaneous emphysema are of limited severity, resulting in minor, localized swelling, and require nothing more than observation and reassurance. However, early recognition of these problems is essential in preventing lifethreatening complications such as airway obstruction, mediastinitis, deep neck infection, and cardiac failure. We review the pathophysiology and clinical course of this disease.

Gasric Rupture as the Result of a Binge-Eating after a Abstinence Prayer

Spontaneous gastric rupture is a very rare disease and may be related to the consumption of large meals. We experienced a rare case of gastric rupture due to binge eating. A 57-year-old woman visited the emergency department with an abdominal distention following binge eating after a two day abstinence prayer. A plain abdominal X-ray showed free air in the subphrenic space and a markedly distended stomach. At laparotomy, the stomach was dilatated and ruptured about 7 cm from the esophagogastric junction to the lesser curvature. A total gastrectomy was done, but at 11 days, the patient expired due to sepsis. Causes of acute gastric dilatation are various and include binge eating. Massive gastric dilatation leads to a decrease in intramural blood flow and gastric infarction. Symptoms of gastric dilatation may be mild, but are progressive. Diagnosis can be made by observing free air or a distended stomach on a simple abdominal X-ray. Treatment should begin with nasogastric decompression and fluid resuscitation. If conservative treatment fails or if gastric infarction or perforation is suspected, surgical intervention is mandatory.

Effects of Octreotide on Small Bowel Obstructions in Rats / 대한소화기학회지

BACKGROUNDS/AIMS: Gastrointestinal decompression by nasogastric or intestinal tubes developed in 1930s has been the only treatment modality for inoperable intestinal obstruction. We hypothesized that the octreotide, a potent inhibitor of intestinal secretion, has a therapeutic potential in intestinal obstruction. METHODS: Forty Sprague-Dawley rats were randomly assigned to four groups. The rats were subjected to complete or partial ileal obstruction. The treated rats received octreotide (100 microgram/kg) while the controls received the same quantity of saline every 12 hours for 24 or 48 hours. After 24 or 48 hours, the volumes of the small bowel contents were measured. The volumes of supernatant and the concentrations of electrolytes in the small bowel contents after centrifugation were also analyzed. The ileal segments proximal to obstruction were harvested, fixed, and stained, and the pathological changes were evaluated with mucosal damage scores. RESULTS: There were no statistical differences in the volume and the electrolyte composition of intestinal fluid among the 4 groups. In the 48 hour complete obstruction group, the octreotide-treated rats showed statistically lower mucosal damage scores than the control rats (p<0.05). CONCLUSIONS: Octreotide exerts mucosal protecting effect on the complete intestinal obstruction rat model.

Design of a Multimedia Telemedicine System for Inter-hospital Emergency Consultation

PURPOSE: The telemedicine systems for both timely decision of patient transfer and accurate direction of patient treatment through remote consultation are required for better patient care in emergency situation. In this paper, we present noble design methods to implement the emergency telemedicine system suitable for emergency consultation. METHODS: The prototype system designed can encompass multimedia components including radiological images, medical record, biological signals, video conferencing and full-quality video, as well as can transmit changing data in real-time. In the first stage, experimental tests at the local networks analyzed the technical aspects of designed systems, and optimize the parameters subjectively to run them with affordable error. In the Second stage, two medical emergency cases were examined between two hospitals, the first was advanced airway management, and second was the management a patient with cardiac problem. RESULTS: Experimental tests at the local networks, all multimedia components can be represented to both terminals without any problems. Two cases of clinical experiment have performed to demonstrate the clinical usefullness. Orotracheal Intubation was done successfully by local hospital physician who was directed by specialist at distant hospital. The second case, a patient with cardiac problem was good managed by specialist via this telemedicine system without any problems. CONCLUSION: Inter-hospital experiments demonstrate the feasibility to be effectively used at emergency department.