Transcatheter Arterial Embolization of a Gluteal Pseudoaneurysm Due to Ground-Level Fall in an Elderly Woman Taking Apixaban.

A 90-year-old woman prescribed with apixaban was admitted to a hospital after a ground-level fall. She was transferred to our hospital for advanced evaluation and treatment. Contrast-enhanced computed tomography showed a pseudoaneurysm inside the right gluteus maximus muscle. Angiography revealed an aneurysm of the peripheral branch of the inferior gluteal artery and multiple slight pseudoaneurysms of the peripheral branch of the internal iliac artery. We performed transcatheter arterial embolization using a gelatin sponge. After embolization, the hemoglobin stabilized. She was transferred to another hospital for rehabilitation. The use of direct oral anticoagulants in the elderly can lead to significant hemorrhage with minimal trauma. Transcatheter arterial embolization is a minimally invasive and safe procedure for such cases of trauma.

A novel scale for predicting delayed intubation in patients with inhalation injury.

BACKGROUND: Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score. METHODS: We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries. RESULTS: Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems. CONCLUSIONS: We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.

Impact of cardiopulmonary resuscitation time on the effectiveness of emergency department thoracotomy after blunt trauma.

PURPOSE: Debate remains about the threshold cardiopulmonary resuscitation (CPR) duration associated with futile emergency department thoracotomy (EDT). To validate the CPR duration associated with favorable outcomes, we investigated the relationship between CPR duration and return of spontaneous circulation (ROSC) after EDT in blunt trauma. METHODS: A retrospective observational study was conducted at three tertiary centers over the last 7 years. We included bluntly injured adults who were pulseless and required EDT at presentation, but excluded those with devastating head injuries. After multivariate logistic regression identified the CRP duration as an independent predictor of ROSC, receiver operating characteristic curves were used to determine the threshold CPR duration. Patient data were divided into short- and long-duration CPR groups based on this threshold, and we developed a propensity score to estimate assignment to the short-duration CPR group. The ROSC rates were compared between groups after matching. RESULTS: Forty patients were eligible for this study and ROSC was obtained in 12. The CPR duration was independently associated with the achievement of ROSC [odds ratio 1.18; 95% confidence interval (CI) 1.01-1.37, P = 0.04], and the threshold CPR duration was 17 min. Among the 14 patients with a short CPR duration, 13 matched with the patients with a long CPR duration, and a short CPR duration was significantly associated with higher rates of ROSC (odds ratio 8.80; 95% CI 1.35-57.43, P = 0.02). CONCLUSIONS: A CPR duration < 17 min is independently associated with higher ROSC rates in patients suffering blunt trauma.

Difference in severity and distribution of bodily injuries following collision between drivers of K-cars and standard vehicles.

BACKGROUND: Although K-cars, small four-wheeled vehicles with an engine capacity of <660 cc, have been used almost exclusively in Japan, they have recently become increasingly popular in other countries. Therefore, reporting the characteristics of bodily injuries sustained by K-car drivers after road traffic accidents (RTAs) may be important not only for health professionals but also for car manufacturers. METHODS: A single-center, retrospective observational study was conducted using prospectively acquired data. Between January 2010 and December 2017, 494 restrained drivers (331 men/163 women with a mean age of 45.1 years) whose vehicles had been severely damaged in RTAs underwent whole-body computed tomography prospectively. They were subsequently dichotomized into 221 K-car drivers and 273 standard vehicle drivers and compared for severity and distribution of bodily injuries. RESULTS: K-car drivers tended to be older and were significantly more likely to be female than standard vehicle drivers. The frequency of subjects with severe bodily injuries significantly higher among K-car drivers than among standard vehicle drivers (21.7% vs. 14.3%; p = 0.04), and the frequency of bowel/mesentery injuries tended to be higher in the former (9.0% vs. 4.4%; p = 0.06). However, the frequency of abdominal solid viscus injuries did not differ significantly between the two groups. Multivariable regression analysis showed that age [odds ratio (OR): 1.022; 95% confidence interval (CI): 0.998-1.047; p = 0.07] and K-cars (OR: 3.708; 95% CI: 0.984-6.236; p = 0.05) tended to be associated with bowel/mesentery injuries in restrained drivers. The frequency of pelvic/hip fractures also tended to be higher in K-car drivers than in standard vehicle drivers (5.9% vs. 2.6%; p = 0.10). By contrast, the severity and frequency of the upper torso injuries were similar between the two groups. CONCLUSIONS: Compared to standard vehicle drivers, K-car drivers seem to experience more severe bodily injuries after severe RTAs. Despite there being no answer for the increased frequency of only hollow viscus injuries but not solid viscus injuries among restrained K-car drivers, advanced age may, at least in part, be responsible. Given the limitations inherent to this study's single-center, retrospective design, multi-center prospective studies are warranted to verify our findings.

Transcatheter arterial embolization for initial hemostasis in a hemodynamically unstable patient with mesenteric hemorrhage: A case report.

Surgical treatment of mesenteric injuries is necessary to control hemorrhage, manage bowel injuries, and evaluate bowel perfusion. It has recently been suggested that some patients can be managed with transcatheter arterial embolization (TAE) for initial hemostasis. We present a hemodynamically unstable patient who was initially managed by TAE for traumatic mesenteric hemorrhage. A 60-year-old man was injured in a motor vehicle accident and transported to our facility. On arrival, the patient was hemodynamically stable, and had abdominal pain. Physical examination revealed a seatbelt sign on the lower abdomen. A contrast-enhanced computed tomography (CT) scan showed intra-abdominal hemorrhage, mesenteric hematoma, and a giant-pseudoaneurysm, but no intra-abdominal free air or changes in the appearance of the bowel wall. After the CT scan, his vital signs deteriorated and surgical intervention was considered, but TAE was performed to control the hemorrhage. After TAE, the patient was hemodynamically stable and had no abdominal tenderness. A follow-up CT scan was performed 2 days later which showed partial necrosis of the transverse colon and some free air. Resection of the injured transverse colon with primary anastomosis was performed. The patient improved and was discharged 35 days after injury. TAE can be effective as the initial hemostatic procedure in patients with traumatic mesenteric hemorrhage.

Necrotizing enterocolitis associated with Clostridium butyricum in a Japanese man.

Case: Necrotizing enterocolitis (NEC) caused by Clostridium butyricum is common in neonates; however, a case of NEC in adults has not been previously reported. An 84-year-old Japanese man developed C. butyricum-related NEC during hospitalization for treatment of stab wounds to the left side of the neck and lower abdomen, without organ damage, and concomitant pneumonia. Outcome: The patient developed acute onset of emesis accompanied by shock during his admission; partial resection of the small intestine was carried out due to necrosis. Pathologic findings showed mucosal necrosis and extensive vacuolation with gram-positive rods in the necrotic small intestine. Blood culture tests revealed C. butyricum infection. The patient's condition improved after the surgery. He was moved to a rehabilitation hospital on day 66. Conclusion: This study suggests that hospitalized adult patients who receive antibiotic treatment are at risk for NEC.

Prognostic significance of acute pain preceding out-of-hospital cardiac arrest.

BACKGROUND: Sudden loss of consciousness (LOC) and chest pain are common manifestations of out-of-hospital cardiac arrest (OHCA). History of acute pain may be helpful in estimating aetiology and prognosis of OHCA victims. The objective of this study was to evaluate the relationship between acute pain at various locations preceding collapse and outcome. METHODS: Clinical data of 250 witnessed, non-traumatic OHCA victims were reviewed, and the incidence of pain based on anatomical distribution was documented. The focus was on identifying the difference between those collapsing with LOC alone and those collapsing with chest pain (CP). Clinical variables predictive of survival were identified using a logistic regression model. RESULTS: Among the 250 victims, 55.2% collapsed with LOC alone. The incidence of acute pain was: 28.0% for CP, 3.2% for headache, 2.8% for abdominal pain and 2.4% for back pain. The overall 6-month survival rate was 7.2%. The LOC group had a significantly higher return of spontaneous circulation (ROSC) rate compared with the CP group (48.6% vs 31.4%, p<0.05). The rate was elevated in the LOC group; however, only when the initial rhythm was non-shockable. There was no significant intergroup difference in the survival rate. Initial shockable rhythm positively and history of cardiovascular diseases negatively predicted survival. None of the victims in the headache, abdominal pain or back pain groups survived. CONCLUSION: The LOC group's seemingly higher ROSC rate may be due to its aetiological heterogeneity. Complaint of a headache, abdominal pain or back pain in OHCA victims carries a poor prognosis.

Successful treatment for descending necrotizing mediastinitis with severe thoracic emphysema using video-assisted thoracoscopic surgery.

Descending necrotizing mediastinitis (DNM) is a rare, highly fatal disease that occurs as a complication of a cervical or odontogenic infection spreading into the mediastinum. We herein report of a 50-year-old man with DNM and severe thoracic emphysema who was successfully treated using surgical drainage by video-assisted thoracoscopic surgery (VATS) and a transcervical approach. Chest enhanced computed tomography on admission revealed massive left pleural effusion, pneumothorax, absolute collapse of the left lung, and a mediastinal shift to the right side with emphysema. We urgently performed left thoracic and mediastinal drainage using VATS. Retropharyngeal and upper mediastinal drainage was performed transcervically on the third hospital day. He recovered and was discharged on hospital day 57. Surgical drainage is the most important therapy in the treatment of DNM, but there is no standard surgical approach. We believe that VATS is a less invasive, effective modality for draining the posterior mediastinum.

Cardiac arrest due to food asphyxiation in adults: resuscitation profiles and outcomes.

AIM: Food asphyxiation is uncommon but unignorable cause of sudden death in the elderly. Several autopsy studies, which identified those at particular risk, have been conducted on the subject. Resuscitation profiles and outcomes of food asphyxiation victims presenting with out-of-hospital cardiac arrest (OHCA) to the emergency department, however, have rarely been reported. METHODS: Data on adults (> or = 20 years) presenting with OHCA after witnessed food asphyxiation were retrieved from an institutional database. Clinical variables were evaluated to identify their demographic characteristics. Their outcomes, represented by return of spontaneous circulation (ROSC) and survival rate, were also investigated. RESULTS: Sixty-nine food asphyxiation victims presenting with OHCA were identified during the 4-year period. Food asphyxiation occurred most frequently in the age group of 71-80 years, followed by that of 81-90 years. The majority of victims had medical conditions that adversely affected mastication/swallowing, such as dementia. Bystander cardiopulmonary resuscitation (CPR) was performed only in 26%, although bystanders often attempted to clear the airway without performing CPR. Despite the high ROSC rate of 78%, only 7% survived to discharge. Asphyxiation-ROSC interval might play a crucial role in determining the outcomes: the interval was < or = 10 min in all survivors, while it was longer than 10 min in all non-survivors. CONCLUSION: Because of their advanced age and debilitating general condition, it may be difficult to substantially improve the outcomes of food asphyxiation victims. Effort should be directed to prevent food asphyxiation, and public education to perform standard CPR for food asphyxiation victims including the Heimlich manoeuvre is warranted.

Early CT signs in out-of-hospital cardiac arrest survivors: Temporal profile and prognostic significance.

AIM: Although computed tomography (CT) signs of ischaemia, including loss of boundary (LOB) between grey matter and white matter and cortical sulcal effacement, in cardiac arrest (CA) survivors are known, their temporal profile and prognostic significance remains unclear; their clarification is necessary. METHODS: Brain CT scans were obtained immediately after resuscitation in 75 non-traumatic CA survivors in a prospective fashion. They were divided into two groups according to the CA-return of spontaneous circulation (ROSC) interval: < or =20 min vs. >20 min. The incidence of the CT signs and predictability of these signs for outcome, assessed 6 months after CA, was evaluated and compared. RESULTS: The incidence of the positive LOB sign was 24% in the < or =20-min group and 83% in the >20-min group, and the difference was statistically significant (p<0.001). The interval of 20 min seemed to be the time window for the LOB development. The incidence of the positive sulcal effacement sign was 0% in the < or =20 min group and 34% in the >20-min group, and the difference was statistically significant (p=0.004). A positive LOB sign was predictive of unfavourable outcome with an 81% sensitivity and 92% specificity. A positive sulcal effacement sign was predictive of unfavourable outcome with a 32% sensitivity and 100% specificity. CONCLUSION: A time window may exist for ischaemic CT signs in CA survivors. The LOB sign may develop when the CA-ROSC interval exceeds 20 min, whereas the sulcal effacement sign may develop later. However, their temporal profile and outcome predictability should be verified by multicentre studies.

Headache, cardiac arrest, and intracranial hemorrhage.

Headache is one of the most common manifestations of non-traumatic intracranial hemorrhage, which is an uncommon, but not rare, cause of cardiac arrest in adults. History of a sudden headache preceding collapse may be a helpful clue to estimate the cause of out-of-hospital cardiac arrest (OHCA). Medical records of witnessed OHCA patients were reviewed to identify those who complained of a sudden headache preceding collapse, and the incidence of intracranial hemorrhage among them as well as their clinical characteristics was investigated retrospectively. During the 12-month period, 124 patients who sustained a witnessed OHCA were treated. Among them, 74 (60%) collapsed without any pain complaint, and only 6 (5%) complained of a sudden headache preceding collapse. All of the six patients were resuscitated: four had a severe subarachnoid hemorrhage (SAH), while the other two had a massive cerebellar hemorrhage. By contrast, 39 of the 74 patients who collapsed without any pain were resuscitated. Among them, another six patients were found to harbor an SAH. Thus, a total of 12 among the 124 witnessed OHCA (10%) sustained a fatal intracranial hemorrhage. While OHCA patients who collapse complaining of a sudden headache are uncommonly seen in the emergency room, they have a high likelihood of harboring a severe intracranial hemorrhage. It should also be reminded that approximately half of patients whose cardiac arrest is due to an intracranial hemorrhage may collapse without complaining of a headache. The prognosis of those with cerebral origin of OHCA is invariably poor, although they may relatively easily be resuscitated temporarily. Focus needs to be directed to avoid sudden death from a potentially treatable cerebral lesion, and public education to promote the awareness for the symptoms of potentially lethal hemorrhagic stroke is warranted.

Subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest: a prospective computed tomography study.

AIM: Aneurysmal subarachnoid haemorrhage (SAH) is a relatively common cause of out-of-hospital cardiac arrest (OHCA). Early identification of SAH-induced OHCA with the use of brain computed tomography (CT) scan obtained immediately after resuscitation may help emergency physicians make therapeutic decision as quickly as they can. METHODS: During the 4-year observation period, brain CT scan was obtained prospectively in 142 witnessed non-traumatic OHCA survivors who remained haemodynamically stable after resuscitation. Demographics and clinical characteristics of SAH-induced OHCA survivors were compared with those with "negative" CT finding. RESULTS: Brain CT scan was feasible with an average door-to-CT time of 40.0 min. SAH was found in 16.2% of the 142 OHCA survivors. Compared with 116 survivors who were negative for SAH, SAH-induced OHCA survivors were significantly more likely to be female, to have experienced a sudden headache, and trended to have achieved return of spontaneous circulation (ROSC) prior to arrival in the emergency department less frequently. Ventricular fibrillation (VF) was significantly less likely to be seen in SAH-induced than SAH-negative OHCA (OR, 0.06; 95% CI, 0.01-0.46). Similarly, Cardiac Trop-T assay was significantly less likely to be positive in SAH-induced OHCA (OR, 0.08; 95% CI, 0.01-0.61). CONCLUSION: Aneurysmal SAH causes OHCA more frequently than had been believed. Immediate brain CT scan may particularly be useful in excluding SAH-induced OHCA from thrombolytic trial enrollment, for whom the use of thrombolytics is contraindicated. The low VF incidence suggests that VF by itself may not be a common cause of SAH-induced OHCA.

Granular cell tumor of the breast preoperatively diagnosed by fine-needle aspiration cytology: report of a case.

Granular cell tumors (GCTs) have a characteristic cytological appearance, and fine-needle aspiration cytology (FNAC) has been suggested to be the diagnostic modality of choice. However, the differential diagnosis has not yet been well described. We herein describe a rare case of GCT of the breast and discuss the differential diagnosis. A 53-year-old woman presented to our hospital with a left breast mass. In clinical and radiological examinations, the mass was suspected to be malignant. Cytologically, the tumor was composed of cohesive groups of cells with a syncytial appearance, and the cells contained abundant, finely eosinophilic cytoplasmic granules and small round-to-slightly-oval nuclei, thus suggesting the presence of benign GCT. The results of immunohistochemical staining supported the proposed deviation from Schwann cells. This case emphasizes the fact that GCTs are a rare but important possibility in the differential diagnosis of breast tumors, and that FNAC may provide clinically useful information on the management of such lesions.