Risky locations for out-of-hospital cardiopulmonary arrest in a typical urban city.

BACKGROUND: The aim of this study is to clarify the circumstances including the locations where critical events resulting in out-of-hospital cardiopulmonary arrest (OHCPA) occur. MATERIALS AND METHODS: Subjects of this population-based observational case series study were the clinical records of patients with nontraumatic and nonneck-hanging OHCPA. RESULTS: Of all 1546 cases, 10.3% occurred in a public place (shop, restaurant, workplace, stations, public house, sports venue, and bus), 8.3% on the street, 73.4% in a private location (victim's home, the homes of the victims' relatives or friends or cheap bedrooms, where poor homeless people live), and 4.1% in residential institutions. In OHCPA occurring in private locations, the frequency of asystole was higher and the outcome was poorer than in other locations. A total of 181 OHCPA cases (11.7%) took place in the lavatory and 166 (10.7%) in the bathroom; of these, only 7 (3.9% of OHCPA in the lavatory) and none in the bath room achieved good outcomes. The frequencies of shockable initial rhythm occurring in the lavatory and in bath room were 3.7% and 1.1% (lower than in other locations, P = 0.011 and 0.002), and cardiac etiology in OHCPA occurring in these locations were 46.7% and 78.4% (the latter higher than in other locations, P < 0.001). CONCLUSIONS: An unignorable population suffered from OHCPA in private locations, particularly in the lavatory and bathroom; their initial rhythm was usually asystole and their outcomes were poor, despite the high frequency of cardiac etiology in the bathroom. We should try to treat OHCPA victims and to prevent occurrence of OHCPA in these risky spaces by considering their specific conditions.

Etiology of out-of-hospital cardiac arrest diagnosed via detailed examinations including perimortem computed tomography.

CONTEXT: The spectrum of the etiology of out-of-hospital cardiopulmonary arrest (OHCPA) has not been established. We have performed perimortem computed tomography (CT) during cardiopulmonary resuscitation. AIMS: To clarify the incidence of non-cardiac etiology (NCE), actual distribution of the causes of OHCPA via perimortem CT and its usefulness. SETTINGS AND DESIGN: Population-based observational case series study. MATERIALS AND METHODS: We reviewed the medical records of 1846 consecutive OHCPA cases and divided them into two groups: 370 showing an obvious cause of OHCPA with NCE (trauma, neck hanging, terminal stage of malignancy, and gastrointestinal bleeding) and others. RESULTS: Of a total OHCPA, perimortem CT was performed in 57.5% and 62.5% were finally diagnosed as NCE: Acute aortic dissection (AAD) 8.07%, pulmonary thrombo-embolization (PTE) 1.46%, hypoxia due to pneumonia 5.25%, asthma and acute worsening of chronic obstructive pulmonary disease 2.06%, cerebrovascular disorder (CVD) 4.48%, airway obstruction 7.64%, and submersion 5.63%. The rates of patients who survived to hospital discharge were 6-14% in patients with NCE. Out of the 1476 cases excluding obvious NCE of OHCPA, 66.3% underwent perimortem CT, 14.6% of cases without obvious NCE and 22.1% of cases with perimortem CT were confirmed as having some NCE. CONCLUSIONS: Of the total OHCPA the incidences of NCE was 62.5%; the leading etiologies were AAD, airway obstruction, submersion, hypoxia and CVD. The rates of cases converted from cardiac etiology to NCE using perimortem CT were 14.6% of cases without an obvious NCE.

Blood transfusion therapy for traumatic cardiopulmonary arrest.

BACKGROUND: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). MATERIALS AND METHODS: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. RESULTS: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. CONCLUSION: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.

Recurrent hepatocellular carcinoma with tumor thrombus in right atrium - report of a successful liver resection with tumor thrombectomy using total hepatic vascular exclusion without concomitant cardiopulmonary bypass.

For resection of advanced hepatocellular carcinoma (HCC) in which tumor thrombus (TT) extends into inferior vena cava (IVC) or right atrium (RA) surgery is challenging and requires skillful techniques. Here, we report a case of recurrent HCC with TT extending to the RA, who underwent successful resection with tumor thrombectomy without concomitant cardiopulmonary bypass. A 71-year-old man, who had been followed- up for hepatitis C by a local hospital, was diagnosed as having HCC in segment 6 for which he had undergone segmentectomy of segment 6 in May 2009. During follow-up, he developed severe leg edema and ascites with investigations revealing recurrent HCC in segment 7 with TT extending to the right atrium via IVC. After transarterial embolization the patient underwent extended resection of the segment 7 with tumor thrombectomy of the IVC and the right atrium and partial resection of the IVC wall using total hepatic vascular exclusion, without concomitant cardiopulmonary bypass. Total ischemic time was 23 minutes, operation time was 6 hours and blood loss was 2,474mL. The postoperative course was uneventful. Histopathology was recurrent hepatocellular carcinoma with hepatic venous invasion. We report the case of resected recurrent HCC with TT extending to right atrium without concomitant cardiopulmonary bypass.

Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest.

BACKGROUND: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. MATERIALS AND METHODS: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients' medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. RESULTS: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. CONCLUSION: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

Surgical inflammation induces hepcidin production after abdominal surgery.

BACKGROUND: Hepcidin, a key regulator of iron homeostasis, is also a marker of acute inflammation. In the present study we investigated the changes in the serum hepcidin level and correlations between hepcidin and other markers of acute inflammation during the perioperative period in patients after abdominal surgery. METHODS: Serum hepcidin, hemoglobin (Hb), hematocrit (Ht), white blood cell (WBC) count, frequency of neutrophils, and C-reactive protein (CRP) were measured preoperatively (Pre), and on postoperative days (POD) 1, 3, 7, and 14. RESULTS: In patients undergoing gastrectomy, the median levels of hepcidin preoperatively and on POD 1, 3, 7, and 14 were 6.5, 53.1, 31.7, 15.6, and 4.0 ng/dl, respectively (p < 0.0001). The corresponding levels in colectomy patients were 8.5, 78.3, 60.1, 49.7, and 8.4 ng/dl, respectively (p = 0.0002); those in hepatectomy patients were 6.6, 16.3, 3.5, 13.4, and 3.4 ng/dl, respectively (p = 0.0022); and those in patients undergoing surgery for diffuse peritonitis were 24.8, 50.1, 43.1, 31.2, and 31.7 ng/dl, respectively (p = 0.4933). There were no significant decreases in Hb and Ht in the patients undergoing gastrectomy, colectomy, or surgery for diffuse peritonitis. The level of hepcidin was significantly correlated with the WBC count, frequency of neutrophils, and CRP level during the perioperative period for all four types of operation. CONCLUSIONS: Like other inflammatory markers, an increase in the level of hepcidin (i.e., a hepcidin storm) occurs in the acute phase after gastrectomy, colectomy, hepatectomy, and surgery for diffuse peritonitis.

[Retropharyngo-esophageal hematoma treated by open paramedian tracheostomy].

Forty eight year-old woman with untreated liver cirrhosis was transferred to our critical care and emergency center because of airway crisis due to retropharyngo-esophageal hematoma after slight chest contusion. We performed emergency tracheal intubation beyond stenotic part of the trachea. The hematoma did not diminished in a few days. Although we considered tracheostomy, we hesitated to perform conventional median tracheostomy because of the risk of complication of infection of the hematoma which might require drainage or removal resulting in contamination between tracheostomy site and cervical wound. We performed paramedian tracheostomy by antero-lateral skin incision to avoid these risks. Fortunately, the patient did not require drainage of the retropharyngo-esophageal hematoma. Paramedian tracheostomy should be taken into account for patients with presumably contaminated cervical wound.

Duodenal perforation due to compression necrosis by the tip of percutaneous endoscopic gastrostomy tube.

Percutaneous endoscopic gastrostomy (PEG) is a common and safe procedure for enteral nutrition. There are few reports concerning its complications. We managed a 31-y-old bedridden case with punched out duodenal perforation without inflammation, from which the tip of the PEG tube protruded. Simple x-ray and computed tomography showed incarceration of the balloon in the duodenal bulb and extravasation of the tip of the tube. We performed simple closure with omental patching for duodenal perforation. Postoperative gastrointestinal fiberscopy on the 11th day revealed scar phase. Some PEG tubes have a balloon, which can prevent the removal of the tube, fix the position of the tube, and prevent the leakage of gastric contents from fistula. However, in our case, the inflated balloon was transferred into the duodenal bulb according to gastric strong peristalsis. This pathophysiologic mechanism is the same as ball bulb syndrome, which is known as gastroduodenal obstruction by incarceration of the gastric submucosal tumor. There is a risk of wedging of the inflated balloon of the PEG tube and perforation of the duodenum. We must not insert the tube too deeply, must not continue to inflate the balloon for a long time, and must check its position using a stethoscope, simple x-ray examination, or ultrasound.

Outcomes from prehospital cardiac arrest in blunt trauma patients.

BACKGROUND: There are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system. METHODS: The 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records. RESULTS: Of those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients-11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole-13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7 min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17 min. CONCLUSIONS: In BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

[First death case of serotonin syndrome in Japan induced by fluvoxamine and tandospirone].

We experienced the first death case of the serotonin syndrome in Japan caused by fluvoxamine and tandospirone. A 15-year-old man was transported to our hospital for shock, muscle hypertonia and hyperthermia after cardiopulmonary arrest. His serum concentrations of fluvoxamine and tandospirone were 3,554 ng/mL and 698 ng/mL respectively after 24 hours from oral intake. He was dead in spite of intensive treatments. The progress of the serotonin syndrome is usually rapid. So, it should be monitored appropriately a patient with serotonin syndrome. If he has hyperthermia, immediate paralysis should be induced. We should aware of the serotonin syndrome a case of overdose on a serotonergic agent.

Usefulness and safety of open tracheostomy by a paramedian approach for cervical infection: esophageal and tracheal injury and necrotizing fascitis.

Tracheostomy is hardly performed in patients with cervical infection close to the site of the tracheostomy. This study aimed to present and clarify the usefulness and safety of open tracheostomy performed by the paramedian approach technique. The procedure is as follows. A 2.5-cm paramedian incision is made for the tracheostomy on the opposite side of infectious focus; the anterior neck muscles are dissected and split; the trachea is fenestrated by a reverse U-shaped incision; and the fenestral flap of the trachea is fixed to the skin. We used this technique in five patients. There were no complications such as bleeding, desaturation, and displacement of the tube; and there were no postoperative complications such as severe contamination or infection of the tracheostomy site from the nearby cervical wound, difficulty in securing the tracheostomy tube and connecting device to the ventilator, difficulties in daily management and care, or dislocation of the tracheostomy tube. All wounds resulting from the tracheostomy were kept separate from and not contaminated by the nearby dirty wounds. Open tracheostomy by the paramedian approach technique is useful and safe for patients with severe cervical infection requiring open drainage and long ventilatory management.

Increased hepcidin production impairs iron metabolism after pancreatoduodenectomy.

BACKGROUND: The duodenum is a central organ for iron absorption. This study was performed to evaluate changes in body iron concentration and other iron-related molecules sequentially, in patients undergoing pancreatoduodenectomy (PD). METHODS: Twenty-one patients who had undergone PD at our department were enrolled in the study. Measurements of serum iron (sFe), total iron-binding capacity (TIBC), serum ferritin (sFer), C-reactive protein (CRP), interleukin-6 (IL-6), hemoglobin (Hb), hematocrit (Ht), and serum hepcidin (sHep) were performed before surgery (Pre), and on postoperative days 3 (D3), 7 (D7), and 14 (D14). RESULTS: The median values of sFe on Pre, D3, D7, and D14 were 73.0, 30.0, 33.0, and 41.0 microg/ dL, respectively (P < 0.05), and those of TIBC were 276.0, 160.0, 176.0, and 165.0 microg/ dL, respectively (P < 0.05). CRP and IL-6 became maximal on D3. The median values of sHep on Pre, D3, D7, and D14 were 18.9, 42.9, 25.7, and 21.2 mg/dL, respectively (P < 0.05). Hb and Ht reached minimum values on D3 and remained low until D14. The median values of sFer on Pre, D3, D7, and D14 were 135, 301, 267, and 233 ng/ dL, respectively. CONCLUSIONS: Hepcidin production is increased after pancreatoduodenectomy. Because hepcidin is known to divert iron to storage-type ferritin rather than to erythropoiesis, iron administration intended for erythropoiesis during this period may be ineffective.

eGFR is a reliable preoperative renal function parameter in patients with gastric cancer.

AIM: To evaluate the validity of the estimated glomerular filtration rate (eGFR) as a preoperative renal function parameter in patients with gastric cancer. METHODS: A retrospective study was conducted in 147 patients with gastric cancer. Preoperative creatinine clearance (Ccr), eGFR, and pre- and postoperative serum creatinine (sCr) data were examined. Preoperative Ccr and eGFR were then compared for their reliability in predicting postoperative renal dysfunction. RESULTS: Among 110 patients with normal preoperative Ccr values, 7 (6.3%) had abnormal postoperative sCr values, and among 112 patients with normal preoperative eGFR values, postoperative sCr was abnormal in 5 (4.5%) (P = 0.53). Among 37 patients with abnormal preoperative Ccr values, 30 (81.1%) had normal postoperative sCr values, and of 35 patients with abnormal preoperative eGFR values, postoperative sCr was normal in 25 (71.4%) (P = 0.34). Preoperative Ccr was significantly correlated with eGFR (r = 0.514), and postoperative sCr was significantly correlated with preoperative Ccr (r = -0.334) and eGFR (r = -0.02). CONCLUSION: Preoperative eGFR is as effective as Ccr for predicting postoperative renal dysfunction. eGFR should therefore be used as an indicator of preoperative renal function in place of Ccr since it is a cheaper and easier to perform test.

Cardiopulmonary arrest on arrival due to penetrating trauma.

INTRODUCTION: The aim of this study was to clarify the outcome of patients with cardiopulmonary arrest on arrival due to penetrating trauma (PT-CPA) and to establish the treatment strategy. PATIENTS AND METHODS: The clinical course of 29 patients with PT-CPA over the past 10 years was examined. We have taken three approaches to these patients: (i) an aggressive treatment strategy; (ii) an in-hospital system supporting this aggressive resuscitation; and (iii) the pre-hospital emergency medical service (EMS) system in our city. RESULTS: Although the return of spontaneous circulation (ROSC) was established in 59% of patients, only 17% survived for 7 days, 14% were discharged, and 7% were neurologically intact. Of 10 patients showing pulseless electrical activity (PEA) on the scene, ROSC was established in 100% and 30% were discharged; however, of 12 patients showing asystole, ROSC was established in 33% and no patient could be discharged. There was no difference in the time interval from the arrival at the emergency department to ROSC between discharged patients and patients who died. The time interval from collapse to arrival at the emergency department in discharged patients and patients who went to the intensive care unit was shorter than that of patients who died in the emergency department with and without ROSC. CONCLUSIONS: We cannot decide to give up and terminate resuscitation in any PT-CPA patients and cannot define salvageable patients. However, our data show that 30-min resuscitation is thought to be relevant and that we should not give up on resuscitation because of the time interval without ROSC after arrival at the hospital.

[Experience of damage control as the primary surgery for thoraco-abdominal injury with hemorrhagic shock].

We experienced a traumatic victim with thoracic and abdominal injury with hemorrhagic shock, who was successfully treated with damage control. Thoracic drainage revealed more than 300 ml/hour of continuous hemorrhage in the left thoracic cavity with 60-80 mmHg of non-responding hypotention. Although we performed emergency partial resection of the injured lung, intraabdominal packing and transcatheter arterial embolization, intrathoracic hemorrhage and hemorrhagic shock was not controlled. We decided re-thoracotomy and performed peri-pulmonary packing around the injured lung, by which we successfully controlled temporary intrathoracic hemorrhage and definitive left lower lobectomy. Peri-pulmonary packing was effective for intrathoracic hemostasis without lethal ventilatory and circulatory complication in this case.

Estimated glomerular filtration rate is superior to measured creatinine clearance for predicting postoperative renal dysfunction in patients undergoing pancreatoduodenectomy.

OBJECTIVE: A retrospective study was conducted to compare measured creatinine clearance (Ccr) with estimated glomerular filtration rate (eGFR) as a preoperative renal function test in patients undergoing pancreatoduodenectomy. METHODS: The records of 139 patients undergoing pancreatoduodenectomy were enrolled, and preoperative Ccr, a 3-variable equation for eGFR (eGFR3) and a 5-variable equation for eGFR (eGFR5) were estimated. The maximum increases in the postoperative serum creatinine and urea nitrogen levels were compared between the groups with normal and abnormal levels relative to Ccr, eGFR3, and eGFR5. RESULTS: There were 30 patients with abnormal Ccr levels, 17 with abnormal eGFR3 levels, and 16 with abnormal eGFR5 levels. Postoperative serum creatinine and urea nitrogen levels were significantly higher in patients with eGFR3 and eGFR5 abnormal levels than in patients with eGFR3 and eGFR5 normal levels. Postoperative serum creatinine and urea nitrogen levels tended to be higher in patients with Ccr abnormal level. The sensitivity and specificity of eGFR3 and eGFR5 for postoperative renal dysfunction were better than those of Ccr, and multivariate analysis showed that eGFR5 was the only independent predictive factor for postoperative renal dysfunction. CONCLUSIONS: The eGFR5 and eGFR3, rather than the Ccr, are recommended as preoperative renal function test in patients undergoing pancreatoduodenectomy.

Lethal obstructive colitis: how and when patients with colonic obstruction should be prevented from falling into a lethal condition.

BACKGROUND/AIMS: The objective of this study is to clarify the pathological condition and treatment strategy of lethal obstructive colitis (LOC), which is defined as obstructive colitis with severe shock or septic shock. METHODOLOGY: We examined 5 patients with LOC (colorectal cancer or suspected in 2, fecal impaction in 2, and volvulus in 1) and evaluated their pathophysiology and management strategy from their medical records. RESULTS: Emergency operations were performed within 150 minutes from arrival in all cases. Three were saved by repeat operations and 2 died. The systolic pressure of both survived and deceased patients were under 62 or palpable only on the common carotid artery, and there was no difference between survived and deceased patients. The mean pulse rate of the deceased patients was 76.5 while survived 117.7. Two deceased patients presented unconsciousness or conscious disorder while survived patients showed clear consciousness. The 2 deceased patients fell into VT just after arrival or during the operation. CONCLUSIONS: In managing colonic obstruction, we should be aware of this potentially lethal disease and surgical treatment should be performed as soon as possible before the patients fall into LOC. Early diagnosis and early aggressive surgery is essential for managing LOC.