Critical anterior mediastinal hematoma without internal mammary artery injury caused by cardiopulmonary resuscitation: A case report.

BACKGROUND: Massive anterior mediastinal hematoma due to chest compression during cardiopulmonary resuscitation is often caused by internal mammary artery injury. However, critical massive anterior mediastinal hematoma without damage to major blood vessels is extremely rare. We report a case of life-threatening anterior mediastinal hematoma without internal mammary artery injury during extracorporeal cardiopulmonary resuscitation. CASE PRESENTATION: A 70-year-old man was transferred to our emergency department because of ventricular fibrillation arrest. Manual chest compressions and venoarterial extracorporeal membrane oxygenation were applied in the angiography room. Acute myocardial infarction was diagnosed, and percutaneous coronary intervention with stent placement was performed. Despite the establishment of venoarterial extracorporeal membrane oxygenation flow, the hemodynamics were unstable. Computed tomography revealed a massive anterior mediastinal hematoma compressing the right heart system and causing obstructive shock. Although local incision and anterior mediastinal hematoma drainage were tried for resolving obstructive shock, the patient's anemia did not improve, and there was still continuous hemorrhaging from the drainage tube. A median thoracotomy was then performed. There was no injury of the main trunk of the internal mammary artery but only hemorrhaging from the sternal fracture site. The patient's hemodynamics and anemia improved after hemostasis and gauze packing. Re-thoracotomy for gauze removal and sternal closure was performed three days post-hospitalization. CONCLUSIONS: It is important to consider hemorrhaging and unstable hemodynamics in patients who receive extracorporeal cardiopulmonary resuscitation. Therefore, a thoracotomy may take precedence over intravascular treatment for restoring hemostasis when there is no information regarding the bleeding site, such as the presence of extravasation.

Resuscitative endovascular balloon occlusion of the aorta for ruptured pancreaticoduodenal artery aneurysm.

Resuscitative endovascular balloon occlusion of the aorta is useful as a troubleshooting response to hemorrhage and a temporary method for maintaining patient hemodynamics.

Maximizing Health-Care Capacity in Response to COVID-19 Outbreak: Rapid Expansion Through Education by Health Emergency and Disaster Experts.

Delivering adequate health care in the setting of the ongoing pandemic is challenging. Due to coronavirus disease 2019 (COVID-19), the Tokyo Metropolitan government has been forced to expand their acute health-care capacity corresponding to infectious diseases within a short period. Responding to this situation, health emergency and disaster experts of the Tokyo Disaster Medical Assistance Team took the initiative in creating a brief education course. We established the course for expanding infectious disease care capacity by a dedicated hands-on lecture for health professionals who are unfamiliar with infectious disease care in ordinary circumstances. Our lecture included the typical course of COVID-19, use of personal protective equipment, environmental sterilization, medical-ward zoning, and safe caregiving. Hospitals that received customized lectures reported by means of a questionnaire that the lectures were well suited to their needs. Currently, the health-care system in Tokyo has increased its capacity to meet the demand and has not been affected by COVID-19. Our experience shows that health emergency and disaster experts can assist hospitals in crisis by providing educational materials.

Angiography versus colonoscopy in patients with severe lower gastrointestinal bleeding: a nation-wide observational study.

AIM: Clinical guidelines for acute lower gastrointestinal bleeding (LGIB) recommend non-endoscopic treatment when endoscopic treatment is difficult or the patient is hemodynamically unstable. The aim of this study was to investigate whether angiography should be prioritized as initial treatment for severe LGIB patients over colonoscopy. METHODS: We undertook a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database. We compared adult patients who underwent colonoscopy or angiography within 1 day of admission for severe LGIB from 2010 to 2017. The primary outcome was in-hospital mortality. Secondary outcomes included surgery carried out within 1 day after admission and surgery carried out between 2 and 7 days of admission. Propensity score-matched analyses were undertaken to adjust for confounders. RESULTS: We identified 6,546 eligible patients. The patients were divided into the colonoscopy group (n = 5,737) and angiography group (n = 809). After one-to-four propensity score matching, we compared 3,220 and 805 patients who underwent colonoscopy and angiography, respectively. The angiography group was not significantly associated with reduced in-hospital mortality compared with the colonoscopy group. In contrast, the number of patients who underwent surgery within 1 day of admission was significantly lower in the angiography group than in the colonoscopy group. CONCLUSIONS: The present study revealed that in-hospital mortality did not significantly differ between colonoscopy and angiography, even in severe LGIB patients. Although this study was unable to identify which subgroups should undergo angiography for primary hemostasis, angiography might be a better option than colonoscopy for initial hemostasis in more severe cases of LGIB.

A Case Involving Massive Insulin Overdose: Direct and Indirect Conditions Requiring Extended Management of Serum Potassium.

BACKGROUND Insulin lowers not only blood glucose levels but also serum potassium levels by driving potassium into the cells. Hypokalemia can occur during aggressive treatment of hypoglycemia in patients with insulin overdose and is a well-documented clinical phenomenon; however, there are no studies describing delayed hyperkalemia occurring after initial treatment in patients with insulin overdose. CASE REPORT A 23-year-old male with a history of type 2 diabetes mellitus and self-medicating with insulin, attempted suicide by subcutaneously injecting 2100 units of insulin. He was admitted to our emergency department due to recurrent hypoglycemia. Continuous administration of 50% glucose and potassium via a central venous catheter was performed to maintain his glucose levels above 80 mg/dL and serum potassium level between 3.5 and 4.0 mEq/L. Because his serum potassium level exceeded 4.5 mEq/L at day 3 after admission, the dosage was adjusted accordingly. After his serum potassium level declined to 3.0 mEq/L, his potassium level abruptly increased to 6.0 mEq/L at day 5 after admission. The patient was placed on a potassium-restricted diet and administered furosemide. Potassium infusion was also discontinued. After serum potassium levels returned to the normal range without interventional therapies, the patient was discharged to home on day 14. CONCLUSIONS In cases of high-dose insulin overdose, management of hyperkalemia following recovery from hypoglycemia is a critical aspect of patient management. Conservative administration of potassium to correct initial hypokalemia may be considered in patients with high-dose insulin overdose.

Critical Malperfusion Caused by Central Aortic Repair for Acute Aortic Dissection: A Case Report.

We encountered a case of hepatic malperfusion resulting from central repair for Stanford type A acute aortic dissection (AAD). A 78-year-old woman had AAD, for which ascending aortic repair was performed. Hepatic malperfusion developed 3 days postoperatively. The superior mesenteric and celiac arteries were occluded by a false lumen (FL). We believed that the surgery caused a change in the blood flow in FL. Percutaneous transluminal angioplasty and stenting of the superior mesenteric artery were performed, and the patient's condition improved. Thus, intervention for the branched artery should be performed prior to central repair, depending on the type of malperfusion.

Body temperature change and outcomes in patients undergoing long-distance air medical transport.

BACKGROUND: Short-distance air medical transport for adult emergency patients does not significantly affect patients' body temperature and outcomes. This study aimed to examine the influence of long-distance air medical transport on patients' body temperatures and the relationship between body temperature change and mortality. METHODS: We retrospectively enrolled consecutive patients transferred via helicopter or plane from isolated islands to an emergency medical center in Tokyo, Japan between April 2010 and December 2016. Patients' average body temperature was compared before and after air transport using a paired t-test, and corrections between body temperature change and flight duration were calculated using Pearson's correlation coefficient. Multivariable logistic regression models were then used to examine the association between body temperature change and in-hospital mortality. RESULTS: Of 1253 patients, the median age was 72 years (interquartile range, 60-82 years) and median flight duration was 71 min (interquartile range, 54-93 min). In-hospital mortality was 8.5%, and average body temperature was significantly different before and after air transport (36.7 °C versus 36.3 °C; difference: -0.36 °C; 95% confidence interval, -0.30 to -0.42; p < 0.001). There was no correlation between body temperature change and flight duration (r = 0.025, p = 0.371). In-hospital death was significantly associated with (i) hyperthermia (>38.0 °C) or normothermia (36.0-37.9 °C) before air transport and hypothermia after air transport (odds ratio, 2.08; 95% confidence interval, 1.20-3.63; p = 0.009), and (ii) winter season (odds ratio, 2.15; 95% confidence interval, 1.08-4.27; p = 0.030). CONCLUSION: Physicians should consider body temperature change during long-distance air transport in patients with not only hypothermia but also normothermia or hyperthermia before air transport, especially in winter.

Resuscitative Endovascular Balloon Occlusion of the Aorta Using a Low-Profile Device is Easy and Safe for Emergency Physicians in Cases of Life-Threatening Hemorrhage.

BACKGROUND: Bleeding from hemorrhagic shock can be immediately controlled by blocking the proximal part of the hemorrhagic point using either resuscitative thoracotomy for aortic cross-clamping or insertion of a large-caliber (10-14Fr) resuscitative endovascular balloon occlusion of the aorta (REBOA) device via the femoral artery. However, such methods are very invasive and have various complications. With recent progress in endovascular treatment, a low-profile REBOA device (7Fr) has been developed. OBJECTIVE: The objective of this study was to report our experience of this low-profile REBOA device and to evaluate the usefulness of emergency physician-operated REBOA in life-threatening hemorrhagic shock. METHODS: Ten patients with refractory hemorrhagic shock underwent REBOA using this device via the femoral artery. All REBOA procedures were performed by emergency physicians. The success rate of the insertion, vital signs, and REBOA-related complications were evaluated. RESULTS: Median age was 54 years (interquartile range 33-78 years). The causes of hemorrhagic shock were trauma (n = 4; 1 blunt and 3 penetrating), ruptured abdominal aortic aneurysm (n = 3), and obstetric hemorrhage (n = 3). Two patients had cardiopulmonary arrest upon arrival. REBOA procedure was successful in all patients, and all became hemodynamically stable to undergo definitive interventions after REBOA. There were no REBOA-related complications. The mortality rate within 24 h and 30 days was 40%. CONCLUSIONS: This REBOA device was useful for emergency physicians in life-threatening hemorrhagic shock because of its ease in handling and low invasiveness.

Giant Iliopsoas Abscess Caused by Morganella Morganii.

BACKGROUND While uncommon, iliopsoas abscesses can become the underlying cause of a fever of unknown origin. Even in such cases, it is considered rare for an iliopsoas abscess to extend into the subcutaneous space. CASE REPORT A 74-year-old woman with a history of schizophrenia was referred to our hospital with a high-grade fever. The patient was unaware of her febrile status prior to admission. There was no previous hospital admission. Examination revealed a non-tender mass in the lower right back that the patient had been aware of for approximately 1 month. Initially, we considered a subcutaneous abscess; however, computed tomography (CT) detected a large mass in the right retroperitoneum, which extended into the adjacent subcutaneous space. Surgical drainage was performed. M. morganii was detected in fluid evacuated from the abscess and in a urine culture. Blood cultures were negative. A repeat enhanced CT revealed a right renal abscess with staghorn calculus. This iliopsoas abscess was considered to be due to a renal abscess. The combination of a minimally aggressive bacterial species and the absence of disease awareness resulted in uncontrolled abscess growth in this case. Surgical drainage and salvage nephrectomy was subsequently performed, and she was discharged to a nursing home. CONCLUSIONS M. morganii can lead to massive abscess formation without an underlying immunocompromised status. Iliopsoas abscesses can surreptitiously extend into the subcutaneous space; therefore, not all abscesses observable from the surface are necessarily subcutaneous in origin.

Independent risk factors for a complicated hospital course in intensive care unit overdose patients.

Aim: The purpose of the present study was to identify risk factors associated with a complicated hospital course in overdose patients admitted to the intensive care unit. Methods: A total of 335 overdose patients were retrospectively studied in the surgical and medical intensive care unit of an academic tertiary hospital. Factors possibly associated with a complicated hospital course were evaluated. Complicated hospital course was defined as the occurrence of pneumonia, rhabdomyolysis, decubitus ulcer, nerve palsy, prolonged intubation, prolonged hospitalization, or death. Results: Of the 335 overdose patients, 93 (27.8%) had a complicated hospital course. Complicated hospital course was found to be associated with a high number of ingested pills (median, 135 [interquartile range, 78-240] versus 84 [53-134] tablets, P < 0.0001), low Glasgow Coma Scale score on admission (7 [3-11] versus 13 [8-15], P < 0.0001), and a high serum lactate level on admission (1.8 [1.0-3.0] versus 1.4 [0.9-2.0] mg/dL, P < 0.01) on univariate analysis of these factors in patients with and without a complicated hospital course. The independent risk factors for a complicated hospital course identified on multivariate analysis were a high number of ingested pills (≥100 tablets), low admission Glasgow Coma Scale score (<9), and high serum lactate on admission (≥2.0 mg/dL). The probability of a complicated hospital course for patients with 0, 1, 2, or all 3 independent risk factors were 7%, 22%, 40%, and 81%, respectively. Conclusion: The total number of ingested pills, admission Glasgow Coma Scale score, and serum lactate level on admission are predictive of a complicated hospital course in overdose patients admitted to the intensive care unit.