Non-occlusive mesenteric ischemia during acute stroke management: three case reports.

BACKGROUND: There are many reports of non-occlusive mesenteric ischemia in patients on maintenance hemodialysis and following cardiac surgery. However, there are few reports of non-occlusive mesenteric ischemia in patients with acute stroke. CASE PRESENTATION: We report three cases of non-occlusive mesenteric ischemia with onset during treatment for acute stroke. All of the patients were undergoing strict blood-pressure control, and two patients developed NOMI soon after tracheostomy when enteral nutrition had been resumed. CONCLUSION: Many stroke patients are older adults with risk factors such as arteriosclerosis. Thus, during acute stroke management, there is a possibility that patients may develop non-occlusive mesenteric ischemia due to decreased intestinal blood flow secondary to strict blood-pressure control. This case report implicates early enteral nutrition as a potential etiopathogenic factor of non-occlusive mesenteric ischemia in patients with acute stroke.

A large gastric rupture due to blunt trauma: a case report and a review of the Japanese literature.

Gastric rupture due to blunt trauma is rare, occurring in only 0.07-1.2% of all abdominal blunt traumas. We reported a case with a 10-cm-long hole and review 25 cases in Japan. A 22-year-old man was involved in a traffic accident, 2 h after eating a lot of food. He had suffered muscular defense in the abdomen. An abdominal computed tomography (CT) scan revealed free air, disruption of the gastric wall and a lot of food residue. The laparotomy showed a burst of 10 cm that ran parallel to the long axis from the cardia to the body. A simple closure was primarily performed and drains were placed in the abdominal cavity. The patient was discharged on the 32nd day. Most cases of gastric rupture are diagnosed intraoperatively, but careful evaluation of CT scans and patient interviews are needed to make an accurate preoperative diagnosis.

The incidence of toxic shock syndrome due to nosocomial methicillin-resistant Staphylococcus aureus infection in burn patients: A four-year retrospective cohort study.

Among adult and pediatric patients, concern is growing in regard to toxic shock syndrome (TSS) resulting from methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infection. We investigated the incidence and characteristics of this form of TSS in patients with burn injury who were admitted to our burn care units from January 2008 to December 2011. Of the 244 patients with nosocomial MRSA infection admitted during the study period, TSS occurred in 20 (8.2%) patients whose average age was 42.9 years, average total burn surface area (TBSA) was 31.7%, and average day of TSS appearance was 9.5 days after injury. There were no particular characteristics associated with age, TBSA or day of TSS appearance in these patients. All but 1 patient recovered from TSS within an average of 9.4 days. The incidence of TSS due to nosocomial MRSA infection in these burn patients was higher than expected. TSS due to nosocomial MRSA infection should be considered in burn care.

The effect of 10-min dispatch-assisted cardiopulmonary resuscitation training: a randomized simulation pilot study.

BACKGROUND: Immediate bystander cardiopulmonary resuscitation (CPR) is essential for survival from sudden cardiac arrest (CA). Current CPR guidelines recommend that dispatchers assist lay rescuers performing CPR (dispatch-assisted CPR (DACPR)), which can double the frequency of bystander CPR. Laypersons, however, are not familiar with receiving CPR instructions from dispatchers. DACPR training can be beneficial for lay rescuers, but this has not yet been validated. The aim of this study was to determine the effectiveness of simple DACPR training for lay rescuers. METHODS: We conducted a DACPR simulation pilot study. Participants who were non-health care professionals with no CPR training within 1 year prior to this study were recruited from Nara Medical University Hospital. The participants were randomly assigned to one of the two 90-min adult basic life support (BLS) training course groups: DACPR group (standard adult BLS training plus an additional 10-min DACPR training) or Standard group (standard adult BLS training only). In the DACPR group, participants practiced DACPR through role-playing of a dispatcher and an emergency caller. Six months after the training, all subjects were asked to perform a 2-min CPR simulation under instructions given by off-duty dispatchers. RESULTS: Out of the 66 participants, 59 completed the simulation (30 from the DACPR group and 29 from the Standard group). The CPR quality was similar between the two groups. However, the median time interval between call receipt and the first dispatch-assisted compression was faster in the DACPR group (108 s vs 129 s, p = 0.042). CONCLUSIONS: This brief DACPR training in addition to standard CPR training can result in a modest improvement in the time to initiate CPR. Future studies are now required to examine the effect of DACPR training on survival of sudden CA.

Self-administered alcohol enema causing chemical proctocolitis.

Background: There are few reports of chemical proctocolitis induced by transanal administration of alcohol. Case report: The patient was a 21-year-old male with no medical history. He transanally pumped 1.8 L of 35% alcohol, experienced melena and disturbance of consciousness, and was transported by ambulance to our hospital. Abdominal computed tomography and endoscopy findings indicated ischemic colitis. He was administered conservative treatment and discharged after 9 days of hospital stay. Conclusion: Reports on alcohol-induced chemical proctocolitis are rare. None of the reported cases involved perforation or required surgery, and all were resolved with conservative therapy, as observed in the study patient.

Performance review of regional emergency medical service pre-arrival cardiopulmonary resuscitation with or without dispatcher instruction: a population-based observational study.

Background: To investigate variations in emergency medical service (EMS) pre-arrival cardiopulmonary resuscitation (CPR), including both bystander CPR without dispatch assistance and dispatch-assisted CPR (DACPR). Methods: We carried out an observational study by implementing EMS pre-arrival CPR reports in three fire agencies. We included adult, non-traumatic, and non-EMS witnessed out-of-hospital cardiac arrests. This reporting system comprised the dispatch instruction process and bystander CPR quality based on evaluations by EMS crews who arrived on the scene. Bystander CPR was categorized as "ongoing CPR" if the bystander was performing CPR when the EMS reached the patient's side and "good-quality CPR" if the CPR was performed proficiently. We compared the frequencies of ongoing and good-quality CPR in the bystander CPR already started without dispatch assistance (CPR in progress) group and DACPR group. Results: Of 688 out-of-hospital cardiac arrests, CPR was already started in 150 cases (CPR in progress group). Dispatcher CPR instruction was provided in 368 cases. Among these, callers started chest compressions in 162 cases (DACPR group). Ongoing CPR was performed in 220 cases and was more frequent in the DACPR group (128/162 [79.0%] versus 92/150 [61.3%], P < 0.001). Good-quality CPR was more frequent in the CPR in progress group, but the difference was not statistically significant (36/92 [39.1%] versus 42/128 [29.0%], P = 0.888). Conclusions: Ongoing CPR and good-quality CPR were not frequent in EMS pre-arrival CPR. Detailed analysis of dispatch instructions and bystander CPR can contribute to improvement in EMS pre-arrival CPR.

Implementation of a dispatch-instruction protocol for cardiopulmonary resuscitation according to various abnormal breathing patterns: a population-based study.

BACKGROUND: We modified the dispatch protocol for cardiopulmonary resuscitation (CPR) using results of a retrospective analysis that identified descriptions by laypersons of possible patterns of agonal respiration. The purpose of this study was to assess the effectiveness of this modified protocol by comparing the frequency of dispatch instructions for CPR and bystander CPR before and after protocol implementation. We also identified descriptions of abnormal breathing patterns among 'Not in cardiac arrest (CA)' unresponsive cases. METHODS: This study was conducted prospectively using the population-based registry of out-of-hospital cardiac arrests (OHCAs). For 8 months we implemented this modified protocol in cooperation with 4 fire departments that cover regions with a total population of 840,000. RESULTS: There were 478 and 427 OHCAs before and after implementation, respectively. Among them, 69 and 71 layperson-witnessed OHCAs for pre- and post-implementation, respectively, were analyzed. Dispatchers provided CPR instructions more frequently after protocol implementation than before (55/71 [77.5 %] vs. 41/69 [59.4 %], p < 0.05). Based on breathing patterns described by emergency callers, dispatchers assessed 143 'Not in CA' unresponsive cases and provided CPR instruction for 45 cases. Sensitivity and specificity of this protocol was 93 % and 50 %, respectively. CONCLUSIONS: This modified protocol based on abnormal breathing described by laypersons significantly increased CPR instructions. Considering high sensitivity and low specificity for abnormal breathing to identify CA and the low risk of chest compression for 'Not in CA' cases, our study suggested that dispatchers can provide CPR instruction assertively and safely for those unresponsive individuals with various abnormal breathing patterns.

Abnormal breathing of sudden cardiac arrest victims described by laypersons and its association with emergency medical service dispatcher-assisted cardiopulmonary resuscitation instruction.

BACKGROUND: Current guidelines for cardiopulmonary resuscitation (CPR) emphasise that emergency medical service (EMS) dispatchers should identify sudden cardiac arrest (CA) with abnormal breathing and assist lay rescuers performing CPR. However, lay rescuers description of abnormal breathing may be inconsistent, and it is unclear how EMS dispatchers provide instruction for CPR based on the breathing status of the CA victims described by laypersons. METHODS AND RESULTS: To investigate the incidence of abnormal breathing and the association between the EMS dispatcher-assisted CPR instruction and layperson CPR, we retrospectively analysed 283 witnessed CA cases whose information regarding breathing status of CA victims was available from population-based prospective cohort data. In 169 cases (59.7%), laypersons described that the CA victims were breathing in various ways, and that the victims were 'not breathing' in 114 cases (40.3%). Victims described as breathing in various ways were provided EMS dispatch-instruction for CPR less frequently than victims described as 'not breathing' (27.8% (47/169) vs 84.2% (96/114); p<0.001). Multivariate logistic regression showed that EMS dispatch-instruction for CPR was associated significantly with layperson CPR (adjusted OR, 11.0; 95% CI, 5.72 to 21.2). CONCLUSIONS: This population-based study indicates that 60% of CA victims showed agonal respiration, which was described as breathing in various ways at the time of EMS call. Although EMS dispatch-instruction was associated significantly with an increase in layperson CPR, abnormal breathing was associated with a much lower rate of CPR instruction and, in turn, was related to a much lower rate of bystander CPR.

Regional tissue oxygen saturation measured by near-infrared spectroscopy to assess the depth of burn injuries.

UNLABELLED: The burn severity depends on the wound depth and area affected. Hitherto burn depth has been judged mainly by visual observation, although concerns have been raised about its validity. The regional tissue blood flow (rTBF) measured by laser Doppler imaging (LDI) in damaged tissue correlates with the depth. However, very few reports are available on the significance of the regional tissue oxygen saturation (rSO2) as an indicator of burn depth. We investigated whether rSO2 by Near-infrared spectroscopy (NIRS) in burn injuries correlates with rTBF by LDI, which would facilitate quantification of the severity of the tissue damage. METHODS: We measured rTBF and rSO2 in 50 lesions from 14 patients of burn injury within 24 hours after injury. The correlation between rTBF and rSO2 was evaluated by Spearman rank correlation analysis. RESULTS: The rSO2 (%; range, 52-82) by NIRS and the rTBF (perfusion unit; range, 61-704) by LDI in burn lesions were positively correlated (r=0.755, p<0.001). This statistically positive correlation still remained significant (r=0.678, p<0.001) after the rSO2 values were standardized. CONCLUSION: This study suggests that NIRS determination of rSO2 in burn injuries shows promise as a reliable and quick method to estimate the depth of burn lesion.

Ratio of von Willebrand factor propeptide to ADAMTS13 is associated with severity of sepsis.

Von Willebrand factor (VWF)-cleaving protease (ADAMTS13) cleaves ultralarge VWF (ULVWF) secreted from endothelium and by which is regulating its physiologic function. An imbalance between ULVWF secretion and ADAMTS13 level occurs in sepsis and may cause multiple organ dysfunction. We evaluated the association between the VWF-propeptide (VWF-pp)/ADAMTS13 ratio and disease severity in patients with severe sepsis or septic shock. In 27 patients with severe sepsis or septic shock and platelet count less than 120,000/µL, we measured plasma VWF, VWF-pp, and ADAMTS13 levels on hospital days 1, 3, 5, and 7. The VWF-pp/ADAMTS13 ratio was increased greater than 12-fold in patients with severe sepsis or septic shock on day 1 and remained markedly high on days 3, 5, and 7 compared with normal control subjects. The VWF-pp/ADAMTS13 ratio significantly correlated with Acute Physiology and Chronic Health Evaluation II score on days 1 and 5; Sepsis-related Organ Failure Assessment score on days 1, 3, and 5; maximum Sepsis-related Organ Failure Assessment score and tumor necrosis factor α level on days 1, 3, 5, and 7; and creatinine level on days 1, 5, and 7. Patients with greater than stage 1 acute kidney injury had significantly higher VWF-pp/ADAMTS13 ratio than patients without acute kidney injury. In summary, the VWF-pp/ADAMTS13 ratio was associated with disease severity in patients with severe sepsis or septic shock and may help identify patients at risk for multiple organ dysfunction by detecting severe imbalance between ULVWF secretion and ADAMTS13 level.

Out-of-hospital cardiac arrest caused by acute intoxication.

We experienced 20 cases of out-of-hospital cardiac arrest (OHCA) caused by acute intoxication between April 1999 and March 2008. The causative agents were organophosphates in 8 cases, carbon monoxide in 5 cases, and barbiturates in 3 cases. Other agents were paraquat, tricyclic anti-depressants, lime sulfur, and amphetamine. Cardiac arrest was witnessed by bystanders while waiting for the ambulance arrival in 3 cases, and by emergency medical personnel during transfer to our hospital in 4 cases. In these 7 witnessed cases, prehospital resuscitation was provided in 6 cases. No case demonstrated ventricular arrhythmia at the prehospital scene. The restoration of spontaneous circulation was achieved in 8 cases, and 4 cases were discharged alive with overall performance category 1. All the survivors were victims of organophosphate or barbiturate intoxication. It is assumed that these agents caused myocardial depression or respiratory insufficiency following cardiac arrest. From the review of the OHCA caused by organophosphate or barbiturate intoxication, cardiopulmonary resuscitation alone seemed to be effective for restoration of spontaneous circulation and should be emphasized in the prehospital care setting as well as in cardiogenic OHCA.

Clinical significance of elevated natriuretic peptide levels and cardiopulmonary parameters after subarachnoid hemorrhage.

Daily changes in serum concentrations of natriuretic peptides and various cardiopulmonary parameters were measured after the onset of subarachnoid hemorrhage (SAH) to investigate the pathogenesis of the cardiac and pulmonary consequences in 15 patients with acute phase SAH, divided into the control group (n = 5) with consciousness continuously preserved from SAH onset to admission, and the consciousness disturbance group (n = 10). Daily changes in serum A-type and B-type natriuretic peptides (ANP and BNP, respectively) were measured for 10 days, and intrathoracic blood volume index and extravascular lung water index (EVLWI) were measured for 5 days by the single transpulmonary thermodilution method. Natriuretic peptides in the consciousness disturbance group showed significantly higher values during the 10-day period, with ANP 119.2 +/- 12.4 pg/ml (mean +/- standard error of the mean, p = 0.005) on day 2 and BNP 354.1 +/- 80.3 pg/ml (p = 0.009) on day 1. EVLWI showed higher values in the consciousness disturbance group compared to the control group throughout the 5-day period. The increases in natriuretic peptide levels and increase in pulmonary extravascular water content found in SAH patients with consciousness disturbance show that load on the left ventricle or atrium as well as pulmonary capillary pressure are increased immediately after onset, supporting the contention that excessive release of catecholamines occurs at this time.

Acute pulmonary edema associated with naphazoline ingestion.

In published reports of naphazoline ingestion, clinical effects are hypertension, bradycardia, pallor, diaphoresis, and respiratory distress. We report three cases of acute pulmonary edema after the intentional ingestion of naphazoline-containing antiseptic first aid liquid. These cases presented with altered mental status, hypertension, bradycardia, and diaphoresis. Chest x-ray on admission revealed acute pulmonary edema. Two cases required mechanical ventilation. All of these clinical effects resolved within 24 hours and the patients were discharged with no sequelae. Since naphazoline stimulates the peripheral alpha-2 adrenergic receptor, we speculate that intense vasoconstriction may have elevated cardiac afterload and left atrial-ventricular blood volume and caused acute pulmonary edema.

Clinical analysis of seven patients of crushing head injury.

BACKGROUND: Crushing head injuries (CHI) are caused by static loading. This static force slowly deforms a cranium and damages some intracranial components. Severe CHI is usually fetal but substantial brain damage may not be recognized in some patients. In this article, we report seven patients who sustained CHI and analyzed clinical and radiological findings. METHODS: In seven patients who sustained CHI, the following factors were analyzed: epidemiological features, neurological findings, and neuroradiological findings. RESULTS: The present series included three males and four females. Mean age was 5.9 years. Six patients had the heads run over by automobiles. One patient had the head crushed by press machine. Epistaxis in six patients and otorrhagia in five patients was recognized. Mean Glasgow coma scale at admission was 8.1. Multiple linear fractures were recognized in four patients and skull base fractures in six patients. Pneumocephalus in five patients and cerebrospinal fluid leakage in seven patients was recognized. One patient underwent evacuation of ASDH and dural plasty. Four patients died and three survived and had only cranial nerve palsies, which recovered completely. CONCLUSION: This injury actually has seldom been countered in daily practice and clinical manifestation and neuroimaging have characteristic features. The prognosis of CHI may be polarized to fatal or excellent, and depends on whether the cranium and brain itself can tolerate the applied force.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by physical exertion.

The clinical characteristics of perimesencephalic nonaneurysmal subarachnoid hemorrhage (SAH) caused by physical exertion were analyzed to investigate the causes and mechanisms of perimesencephalic nonaneurysmal SAH. Nine of 209 patients with spontaneous SAH were identified as having perimesencephalic nonaneurysmal SAH. Perimesencephalic nonaneurysmal SAH in four males and three females was precipitated by exertion. Age, sex predominance, type of exertion, symptoms, loss of consciousness during bleeding, clinical grade, angiographic spasm, hydrocephalus, delayed ischemic deficit, rebleeding, hypertension, and outcome were evaluated in these seven patients. Outcomes were assessed using the Glasgow Outcome Scale. Patients showed male predominance (57.1%), relatively young age (mean 50 years), low frequency of hypertension (28.6%), good clinical grade (World Federation of Neurological Surgeons grade I or II), and excellent outcomes including no rebleeding, no symptomatic hydrocephalus, and no delayed ischemic deficits. The type of exertion was swimming in two patients, golfing in two patients, heavy lifting in two patients, and bending forward during gymnastics in one patient. Physical exertion including components of the Valsalva maneuver is an important predisposing factor for perimesencephalic nonaneurysmal SAH. Such physical exertion produces increased intrathoracic pressure, which blocks the internal jugular venous return, resulting in elevated intracranial venous pressure or mechanical swelling of the intracranial veins, and leads to venous or capillary breakdown.

Magnetic resonance images in hanging.

Hanging is a devastating method of suicide and unfortunately is common in Japan. Although several CT findings of the head have been reported, there have not been any reports about magnetic resonance imaging (MRI) in hanging. We report here interesting MRI findings in a patient after hanging. A 39-year-old woman was transferred to our department after attempting suicide by hanging. Respiration had probably ceased for about three minutes but heart had not stopped when she was pulled down by her father. After her father performed cardiopulmonary resuscitation, she started to breathe immediately. She was treated conservatively in our intensive care unit for 14 days, her condition became stable. Ten days after admission, MRI demonstrated symmetrical hyperintensity on T1-weighted images and relative hyperintensity on T2 weighted images in bilateral lentiform nuclei and medial thalami. There have been several reports about characteristic MRI findings in the case of acute global cerebral ischaemia caused by severe hypoglycaemia or longstanding cardiopulmonary arrest. It was postulated that these specific findings reflected tissue degeneration, deposition of mineral substances, or lipid accumulation. These MRI findings suggest that severe acute global cerebral hypoperfusion also occurs in hanging in the same way as in long-standing cardiopulmonary arrest and that hanging has devastating sequelae.

Prognostic factors in hanging injuries.

The objectives of this study were to review variable factors influencing outcomes in hanging and to identify prognostic factors related to outcomes. Forty-seven patients presented to our department. Eleven patients survived and 36 died. A significant difference in mean hanging time was observed between survivor (11.8 +/- 8.37 minutes) and nonsurvivor (50.81 +/- 61.9). In survivors, heartbeat was recognized in 63.6% at the scene and in 90.9% on arrival. Conversely, cardiopulmonary arrest (CPA) was recognized in all nonsurvivors and heartbeat was recognized on arrival in only 5.6%. Thirty-nine (83%) had a Glasgow Coma Score (GCS) of 3 on arrival. Three (7.7%) of theses 39 patients survived. In survivors, eight patients had a GCS greater than 3. A significant difference in outcome existed between patients with a GCS of 3 and those with a GCS greater than 3. Hanging time, presence of CPA at the scene and on arrival, and GCS on arrival represented prognostic factors of outcome in hanging.