An Unusual Presentation of Chest Pain and Laryngeal Discomfort in a Pregnant Woman: A Case Report and Literature Review.

Intramural esophageal dissection (IED), characterized by bleeding into the submucosal space, leads to mucosal separation and dissection. The most prevalent symptoms are sudden chest or retrosternal pain, hematemesis, and dysphagia. Therefore, acute coronary syndrome and aortic dissection are among its most notable differential diagnoses. A 31-year-old pregnant woman presented with acute chest pain, laryngeal discomfort, and hematemesis. Emergency esophagogastroscopy revealed longitudinal mucosal dissection (upper esophagus to esophagogastric junction). The patient was successfully treated by avoiding the ingestion of solid foods. Clinicians should consider a diagnosis of IED for pregnant patients with acute chest pain, especially if hematemesis is present.

Transversal Survey of Emergency Medicine Policy and Quality Metrics in Japan's Regional Health Care Plans.

Introduction: It is essential to establish appropriate medical quality metrics and make improvements to safely and efficiently deliver optimum emergency medical services. The Ministry of Health, Labor and Welfare (MHLW) recommends prefectures to establish numerical quality metrics in their regional healthcare plans (RHCP). The 7th RHCP was issued by the MHLW in 2017 along with a notice of planning in covering the six-year period from 2018 to 2023. In this descriptive study, the emergency medicine policies in the 7th RHCP of each prefecture were analyzed from a quality improvement perspective. Method: The authors examined the chapters on emergency medicine in the RHCPs of 47 prefectural governments for the overall structure, cost-benefits, and connection to community-based integrated care systems. The type and number of clinical measures listed as numerical metrics and their classification methods were emphasized. Result: Regarding the overall plan structure, 40 prefectural governments began their description with an analysis of current surroundings. In total, 24 prefectural governments mentioned community-based integrated care systems but none mentioned cost-benefit analysis. Altogether, only 43 of 47 prefectural governments (91%) indicated numerical metrics. The maximum number of numerical targets for quality measures by prefecture was 19, the minimum was 0, and the median was 4 (IQR: 3-6.5); there were 220 metrics in total, with 82 structural, 96 process, and 42 outcome measures. Additionally, 13 prefectures (28%) classified quality measures according to the MHLW's guidance, 6 (13%) used their own classification manner, while the others did not classify their measures. Conclusions: There were significant differences in emergency medicine policies and quality metrics among the prefectural governments. Further research is needed to develop and establish more comprehensive and appropriate metrics based on a common methodology to improve the quality of emergency medicine.

Collapse-related traumatic intracranial hemorrhage following out-of-hospital cardiac arrest: A multicenter retrospective cohort study.

Background: Sudden loss of consciousness as a result of cardiac arrest can cause severe traumatic head injury. Collapse-related traumatic intracranial hemorrhage (CRTIH) following out-of-hospital cardiac arrest (OHCA) may be linked to poor neurological outcomes; however, there is a paucity of data on this entity. This study aimed to investigate the frequency, characteristics, and outcomes of CRTIH following OHCA. Methods: Adult patients treated post-OHCA at 5 intensive care units who had head computed tomography (CT) scans were included in the study. CRTIH following OHCA was defined as a traumatic intracranial injury from collapse due to sudden loss of consciousness associated with OHCA. Patients with and without CRTIH were compared. The primary outcome assessed was the frequency of CRTIH following OHCA. Additionally, the clinical features, management, and consequences of CRTIH were analyzed descriptively. Results: CRTIH following OHCA was observed in 8 of 345 enrolled patients (2.3%). CRTIH was more frequent after collapse outside the home, from a standing position, or due to cardiac arrest with a cardiac etiology. Intracranial hematoma expansion on follow up CT was seen in 2 patients; both received anticoagulant therapy, and one required surgical evacuation. Three patients (37.5%) with CRTIH had favorable neurological outcomes 28 days after collapse. Conclusions: Despite its rare occurrence, physicians should pay special attention to CRTIH following OHCA during the post-resuscitation care period. Larger prospective studies are warranted to provide a more explicit picture of this clinical condition.

The Impact of Medical Students Teaching Basic Life Support to Laypersons.

Basic life support (BLS) courses for laypersons, including cardiopulmonary resuscitation (CPR) training, is known to improve outcomes of out-of-hospital cardiac events. We asked medical students to provide BLS training for laypersons as a part of their emergency medicine education and evaluated the effects of training on the BLS skills of laypersons. We also used a questionnaire to determine whether the medical students who provided the BLS training were themselves more confident and motivated to perform BLS compared to students who did not provide BLS training. The proportions of laypersons who reported confidence in checking for a response, performing chest compressions, and automated external defibrillator (AED) use were significantly increased after the BLS training. The proportions of medical students who reported increased confidence/motivation in terms of understanding BLS, checking for a response, chest compression, use of AED, and willingness to perform BLS were significantly greater among medical students who provided BLS instructions compared to those who did not. BLS instruction by medical students was associated with an improvement in laypersons' CPR accuracy and confidence in responding to cardiac arrest. The results indicate that medical students could gain understanding, confidence, and motivation in regard to their BLS skills by teaching BLS to laypersons.

Arrhythmogenic Right Ventricular Cardiomyopathy Diagnosed during Hospitalization for Cardiac Arrest.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a genetically mediated cardiomyopathy charac-terized by progressive myocardial loss of the right ventricle and its replacement by fibrofatty tissue, causing dyskinesia, aneurysm, and/or arrhythmia. The prevalence of ARVC is estimated to be 1 in 2,000-5,000, with the condition accounting for up to 20% of sudden cardiac deaths in individuals < 35 years old. This report describes the case of 61-year-old Japanese who was diagnosed with ARVC after cardiac arrest (CA) and successful resusci-tation. After the sudden CA, the restoration of spontaneous circulation was achieved with appropriate resusci-tation, followed by the introduction of target temperature management in the intensive care unit. He was diag-nosed with ARVC based on angiography and histology results. An ICD (implantable cardioverter-defibrillator) was implanted, and he was discharged without neurological sequelae 1 month post-CA. ARVC is an important cause of sudden CA, and successfully resuscitated patients with right ventricular dilation should undergo testing to rule out ARVC.

State-of-the-art methods for the treatment of severe hemorrhagic trauma: selective aortic arch perfusion and emergency preservation and resuscitation-what is next?

Trauma is a primary cause of death globally, with non-compressible torso hemorrhage constituting an important part of "potentially survivable trauma death." Resuscitative endovascular balloon occlusion of the aorta has become a popular alternative to aortic cross-clamping under emergent thoracotomy for non-compressible torso hemorrhage in recent years, however, it alone does not improve the survival rate of patients with severe shock or traumatic cardiac arrest from non-compressible torso hemorrhage. Development of novel advanced maneuvers is essential to improve these patients' survival, and research on promising methods such as selective aortic arch perfusion and emergency preservation and resuscitation is ongoing. This review aimed to provide physicians in charge of severe trauma cases with a broad understanding of these novel therapeutic approaches to manage patients with severe hemorrhagic trauma, which may allow them to develop lifesaving strategies for exsanguinating trauma patients. Although there are still hurdles to overcome before their clinical application, promising research on these novel strategies is in progress, and ongoing development of synthetic red blood cells and techniques that reduce ischemia-reperfusion injury may further maximize their effects. Both continuous proof-of-concept studies and translational clinical evaluations are necessary to clinically apply these hemostasis approaches to trauma patients.

Cardiac arrest due to liquid nicotine intoxication: a case report.

BACKGROUND: With the introduction of electronic cigarettes, reports of nicotine intoxication due to ingestion of large amounts of liquid nicotine have increased. This report presents a rare case of cardiac arrest due to nicotine intoxication that was successfully treated with appropriate respiratory and circulatory support. CASE PRESENTATION: A 55-year-old man ingested 600 mg of liquid nicotine and developed sinus bradycardia followed by asystole. Appropriate and prompt resuscitation led to the return of spontaneous circulation. He was admitted to the intensive care unit and discharged 24 days later without any medical sequelae of nicotine intoxication. CONCLUSION: Ingestion of a large amount of liquid nicotine, as in this case, can result in lethal bradycardia followed by cardiac arrest. Prompt basic life support by paramedic produced good neurological outcomes. Emergency physicians should be aware of the symptoms and appropriate treatment of severe nicotine intoxication.

Retropharyngeal hematoma presenting airway obstruction: A case report.

INTRODUCTION: Blunt neck trauma patients can suffer from an airway emergency and are necessary to careful observation. PRESENTATION OF CASE: A 79-year-old man under anticoagulation therapy presented to our hospital three hours after a fall. Shortly after arrival, he developed dyspnea. Oral intubation was attempted, but with no success; therefore, an emergency tracheotomy was performed. Contrast-enhanced computed tomography (CT) and subsequent angiography revealed active bleeding from a branch of the right ascending cervical artery. Subsequently, the right thyrocervical trunk, which is upstream from the ascending cervical artery, was embolized and hemostasis was achieved. He was discharged 52 days after the emergency admission. DISCUSSION: This is the first case report of an ascending cervical artery injury due to blunt trauma that resulted in an airway emergency. Contrast-enhanced CT and cervical angiography are useful for confirming the area of injury and size of the hematoma. Half of patients with respiratory distress accompanied by a cervical spine injury require definitive airway management within five hours of the injury and all by 24 h. Neck trauma can lead to fatal airway obstruction and careful monitoring is warranted to detect any signs of impeding respiratory obstruction. CONCLUSION: All emergency physicians need to keep their airway management skills updated in order to perform reliably and rapidly in difficult and urgent situations.

Three-year-old traumatic liver injury patient treated successfully using transcatheter arterial embolization.

INTRODUCTION: Liver injury is the most vulnerable to blunt abdominal trauma. Diagnostic evaluation and treatment of blunt liver trauma in children have changed essentially over the last decades. PRESENTATION OF CASE: A 3-year-old girl, weighing 10 kg was run over by a car and admitted to our hospital.　Due to the liver injury and increased intra-abdominal hemorrhage confirmed by computed tomography, emergent transcatheter arterial embolization (TAE) was performed. Hemostasis was successfully obtained without complications. The patient had a good postoperative course and was discharged on the 9th day after admission. DISCUSSION: To the best of our knowledge, this case is the youngest and lowest weight emergency TAE success cases of childhood liver injury. TAE is an alternative to laparotomy and a useful procedure to accomplish nonsurgical management in adult who are hemodynamically stable and have no other associated injury requiring laparotomy. On the other hand, TAE is considered to have some complications in child cases because of the small diameter of the artery and the tendency to spasm. Our case showed that TAE can be a safe option for emergency hemostasis in pediatric trauma cases weighing 10 kg. CONCLUSION: Emergency physicians must be aware that radiological intervention is an important adjunct to management of childhood liver injury.

Orbital Emphysema as a Consequence of Forceful Nose-Blowing: Report of a Case.

Orbital emphysema occurs when air enters the soft tissue surrounding the orbit. Although orbital blowout fractures are often caused by face trauma, nontraumatic orbital fractures can also occur but have been rarely described. Here, a case of orbital and palpebral emphysema caused by forceful nose-blowing is presented. Examination uncovered gross swelling of the right eye and discernable subcutaneous emphysema. The patient had normal eye movement and visual acuity. Orbital computed tomography (CT) revealed orbital emphysema secondary to an orbit floor fracture into the maxillary sinus, resulting from high intranasal pressure upon blowing her nose. The patient received conservative management with antibiotics and was given instructions not to sneeze or blow her nose. She fully recovered and all her symptoms completely resolved.

Factors Affecting the Absorption of Midazolam to the Extracorporeal Membrane Oxygenation Circuit.

Sedatives are administered during extracorporeal membrane oxygenation (ECMO) therapy to ensure patient safety, reduce the metabolic rate and correct the oxygen supply-demand balance. However, the concentrations of sedatives can be decreased due to absorption into the circuit. This study examined factors affecting the absorption of a commonly used sedative, midazolam (MDZ). Using multiple ex vivo simulation models, three factors that may influence MDZ levels in the ECMO circuit were examined: polyvinyl chloride (PVC) tubing in the circuit, use of a membrane oxygenator in the circuit, and heparin coating of the circuit. We also assessed changes in drug concentration when MDZ was re-injected in a circuit. The MDZ level decreased to approximately 60% of the initial concentration in simulated circuits within the first 30 minutes. The strongest factor in this phenomenon was contact with the PVC tubing. Membrane oxygenator use tended to increase MDZ loss, whereas heparin circuit coating had no influence on MDZ absorption. Similar results were obtained when a second dose of MDZ was injected to the second-use circuits.

Ictal Cardiorespiratory Arrest Associated with Status Epilepticus in Panayiotopoulos Syndrome.

A healthy 10-year-old boy vomited during sleep and later complained of abdominal pain; he became drowsy and uncommunicative. At the nearby hospital E.R., he deteriorated rapidly, and his respiratory movements were absent with cardiac arrest. He was immediately resuscitated. Brain MRI showed no abnormalities. EEG revealed an abnormal pattern with recurrent multifocal epileptiform activity over the bilateral occipital and frontal regions during sleep. Based on the clinical/radiological findings we diagnosed Panayiotopoulos syndrome (PS), a benign form of early-onset pediatric epilepsy characterized by autonomic symptoms. Lifethreating cardiopulmonary arrest is rare in PS, but long seizure duration of PS may associate with apnea and bradycardia.

Portal Venous Gas Following Ingestion of Hydrogen Peroxide Successfully Treated with Hyperbaric Oxygen Therapy.

The primary toxicity of hydrogen peroxide results from its interaction with catalase, which liberates water and oxygen. We report the case of a 14-year-old Japanese girl with portal venous gas that was caused by oxygen liberated from intentionally ingested hydrogen peroxide. Although she had a past history of atrial septal defect, recovery without cardiac or neurological sequelae was achieved using hyperbaric oxygen therapy. Emergency physicians must be aware of the danger of liberated oxygen due to hydrogen peroxide ingestion.

Emphysematous cystitis successfully treated with hyperbaric oxygen therapy: case report.

Emphysematous cystitis is an uncommon acute infection of the underlying bladder musculature and mucosa, caused by gas-producing organisms. Here we describe an 87-year-old woman with diabetes mellitus and emphysematous cystitis who was successfully treated with hyperbaric oxygen (HBO2) therapy. Her predisposition of diabetes and infection with gas-producing bacteria was considered to precede the development of emphysematous cystitis. Computed tomography revealed gas accumulation in the bladder wall and lumen. Antibiotics and HBO2 therapy were administered. HBO2 therapy may be beneficial due to the improvement in oxygenation of the tissues affected by the disease. HBO2 is a useful adjunct therapy for the management of severe emphysematous cystitis.

Indirect Calorimetry Measurement of Energy Expenditure Related to Body Position Changes in Healthy Adults.

Early mobilization is advocated to prevent intensive care unit-acquired physical weakness, but the patient's workload and its changes in response to body position changes have not been established. We used indirect calorimetry to determine the energy expenditure (EE) in response to body position changes, and we assessed EE's correlation with respiratory parameters in healthy volunteers: 8 males and 8 females, mean age 23.4±1.3 years. The subjects started in the resting supine position followed by a 30° head-up position, a 60° head-up position, an upright sitting position, a standing position, and the resting supine position. EE was determined in real time by indirect calorimetry monitoring the subject's respiratory rate, tidal volume (VT), and minute volume (MV). The highest values were observed immediately after the subjects transitioned from standing to supine, and this was significantly higher compared to the original supine position (1,450±285 vs. 2,004±519 kcal/day, p<0.01). Moderate correlations were observed between VT and EE (r=0.609, p<0.001) and between MV and EE (r=0.576, p<0.001). Increasing VT or MV indicates an increasing patient workload during mobilization. Monitoring these parameters may contribute to safe rehabilitation. Further studies should assess EE in critically ill patients.

Inhaled hydrogen ameliorates endotoxin-induced bowel dysfunction.

Aim: Gastrointestinal dysmotility frequently occurs during sepsis and multiple organ failure, remaining a major cause of morbidity and mortality in critically ill patients. Previous studies have shown that hydrogen, a new therapeutic gas, can improve various organ damage associated with sepsis. In this study, we investigated the protective efficacies of inhaled hydrogen against lipopolysaccharide (LPS)-induced ileus. Methods: Sepsis was induced in rats and mice by a single i.p. injection of LPS at 15 mg/kg for mice and 5 mg/kg for rats. Four groups of rats and mice including sham/air, sham/hydrogen, LPS/air, and LPS/hydrogen were analyzed. Hydrogen (1.3%) was inhaled for 25 h beginning at 1 h prior to LPS treatment. Gastrointestinal transit was quantified and cytokine levels, as well as neutrophil extravasation, in the intestinal muscularis propria were determined. Results: Lipopolysaccharide challenge remarkably delayed gastrointestinal transit of non-absorbable dextran, associated with increased leukocyte recruitment and upregulation of pro-inflammatory cytokine mRNA expressions in the muscularis propria. Hydrogen significantly prevented LPS-induced bowel dysmotility and reduced leukocyte extravasation, as well as inhibition of inflammatory cytokine expression. In vitro analysis of cytokine levels after LPS treatment of cultured macrophages showed an increase of interleukin-10 by hydrogen regardless of the presence of nitric oxide. Conclusions: This study showed the protective effects of hydrogen inhalation on LPS-induced septic ileus through inhibition of inflammation in the muscularis propria. These inhibitory effects on the pro-inflammatory response may be partially derived from anti-inflammatory cytokine interleukin-10 induction.

Venous thromboembolism in major trauma patients: a single-center retrospective cohort study of the epidemiology and utility of D-dimer for screening.

Aim: Venous thromboembolism (VTE) can be a life-threatening complication after major trauma. The aim of this study was to investigate the epidemiology of VTE and to assess the usefulness of D-dimer for screening for VTE in major trauma cases among the Japanese population. Methods: We examined a single-center retrospective cohort of severely injured trauma patients who had been admitted to the emergency intensive care unit at Okayama University Hospital (Okayama, Japan) from April 2013 through to March 2016. Venous thromboembolism was confirmed by computed tomography angiography and computed tomography venography, which was determined based on the attending physician monitoring daily D-dimer levels. Independent risk factors for VTE were determined by multiple logistic regression analysis. D-dimer levels were evaluated using area under the receiver operating characteristic curve (AUROC) to predict VTE. Results: The study cohort consisted of 204 trauma patients (median Injury Severity Score, 20). Of the 204 patients, 65 (32%) developed VTE. The median time from admission to VTE diagnosis was 10 days. In multiple logistic regression analysis, higher Injury Severity Score and the presence of lower extremity fractures were revealed to be a risk factor for VTE. D-dimer levels at day 10 showed moderate accuracy, of which the AUROC was 0.785 (95% confidence interval, 0.704-0.866; P < 0.001). The cut-off that maximized the Youden index was 12.45 µg/mL. Conclusions: At least one of every three major trauma patients had potential development of VTE at a median of 10 days following admission to the intensive care unit. D-dimer levels on day 10 can be a useful predictor of VTE.

Occult Sources of Bleeding in Blunt Trauma : A Narrative Review.

Worldwide, hemorrhagic shock in major trauma remains a major potentially preventable cause of death. Controlling bleeding and subsequent coagulopathy is a big challenge. Immediate assessment of unidentified bleeding sources is essential in blunt trauma patients with hemorrhagic shock. Chest/pelvic X-ray in conjunction with ultrasonography have been established classically as initial diagnostic imaging modalities to identify the major sources of internal bleeding including intra-thoracic, intra-abdominal, or retroperitoneal hemorrhage related to pelvic fracture. Massive soft tissue injury, regardless of whether isolated or associated with multiple injuries, occasionally causes extensive hemorrhage and acute traumatic coagulopathy. Specific types of injuries, including soft tissue injury or retroperitoneal hemorrhage unrelated to pelvic fracture, can potentially be overlooked or be considered "occult" causes of bleeding because classical diagnostic imaging often cannot exclude such injuries. The purpose of this narrative review article is to describe "occult" or unusual sources of bleeding associated with blunt trauma.

A Successfully Treated Case of Criminal Thallium Poisoning.

Thallium was once commonly used as a household rodent or ant killer, but many countries have banned such use due to unintentional or criminal poisonings of humans. A common initial clinical manifestation of thallium poisoning is gastrointestinal symptoms followed by delayed onset of neurological symptoms and alopecia. These clinical characteristics can provide important diagnostic clues regarding thallium poisoning. Here, we report a 23-year-old woman who was poisoned by a business colleague when she unknowingly drank tea containing the toxic substance several times. The patient was treated with multi-dose activated charcoal with airway protection and Prussian blue.