Comparison of the Clinical Course of COVID-19 Pneumonia and Acute Respiratory Distress Syndrome in 2 Passengers from the Cruise Ship Diamond Princess in February 2020.

BACKGROUND Patients with coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 can rapidly progress to acute respiratory distress syndrome (ARDS). Because clinical diagnosis of ARDS includes several diseases, understanding the characteristics of COVID-19-related ARDS is necessary for precise treatment. We report 2 patients with ARDS due to COVID-19-associated pneumonia. CASE REPORT Case 1 involved a 72-year-old Japanese man who presented with respiratory distress and fever. Computed tomography (CT) revealed subpleural ground-glass opacities (GGOs) and consolidation. Six days after symptom onset, reverse transcription-polymerase chain reaction (RT-PCR) testing confirmed the diagnosis of COVID-19-associated pneumonia. He was intubated and received veno-venous extracorporeal membrane oxygenation (ECMO) 8 days after symptom onset. Follow-up CT revealed large diffuse areas with a crazy-paving pattern and consolidation, which indicated progression of COVID-19-associated pneumonia. Following treatment with antiviral medications and supportive measures, the patient was weaned off ECMO after 20 days. Case 2 involved a 70-year-old Asian man residing in Canada who presented with cough, malaise, nausea, vomiting, and fever. COVID-19-associated pneumonia was diagnosed based on a positive result from RT-PCR testing. The patient was then transferred to the intensive care unit and intubated 8 days after symptom onset. Follow-up CT showed that while the initial subpleural GGOs had improved, diffuse GGOs appeared, similar to those observed upon diffuse alveolar damage. He was administered systemic steroid therapy for ARDS and extubated after 6 days. CONCLUSIONS Because the pattern of symptom exacerbation in COVID-19-associated pneumonia cases seems inconsistent, individual treatment management, especially the CT-based treatment strategy, is crucial.

Placement accuracy of resuscitative endovascular occlusion balloon into the target zone with external measurement.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) should be safely placed at zone 1 or 3, depending on the location of the hemorrhage. Ideally, REBOA placement should be confirmed via fluoroscopy, but it is not commonly available for trauma bays. This study aimed to evaluate the accuracy of REBOA placement using the external measurement method in a Japanese trauma center. METHODS: A retrospective review identified all trauma patients who underwent REBOA and were admitted to our trauma center from 2008 to 2018. Patient characteristics, REBOA placement accuracy, and complications according to target zones 1 and 3 were reviewed. RESULTS: During the study period, 38 patients met our inclusion criteria. The in-hospital mortality rate was 57.9%. REBOA was mainly used for bleeding from the abdominal (44.7%) and pelvic (36.8%) regions. Of these, 30 patients (78.9%) underwent REBOA for target zone 1, and 8 patients (21.1%) underwent REBOA for target zone 3. The proportion of abdominal bleeding source in the target zone 1 group was greater than that in the target zone 3 group (56.7% vs. 0%). Overall, the proportion of REBOA placement was 76.3% in zone 1, 21.1% in zone 2, and 2.6% in zone 3. The total REBOA placement accuracy was 71.1%. At each target zone, the REBOA placement accuracy for target zone 3 was significantly lower than that for target zone 1 (12.5% vs. 86.7%, p<0.001). No significant associations between non-target zone placement and patient characteristics, complications, or mortality were found. CONCLUSIONS: The REBOA placement accuracy for target zone 3 was low, and zone 2 placement accounted for 21.1% of the total, but no complications and mortalities related to non-target zone placement occurred. Further external validation study is warranted. LEVEL OF EVIDENCE: Level IV.

Effectiveness and Usage Trends of Hemorrhage Control Interventions in Patients with Pelvic Fracture in Shock.

BACKGROUND: Hemorrhage control for pelvic fractures remains challenging. There are several kinds of hemostatic interventions, including angiography/angioembolization (AG/AE), external fixation (EF), and resuscitative endovascular balloon occlusion of the aorta (REBOA). However, no large studies have been conducted for the comparative review of each intervention. In this study, we examined the usage trend of therapeutic interventions in Japan for patients with pelvic fractures in shock and the influence of these interventions on mortality. METHODS: Data of adult patients with pelvic fracture who were in shock were obtained from the Japanese Trauma Data Bank (2004-2014). The primary endpoint was the influence of each intervention (AG/AE, EF, and REBOA) on in-hospital mortality. We also investigated the frequency of each intervention. RESULTS: A total of 3149 patients met all our inclusion criteria. Specifically, 1131 (35.9%), 496 (15.8%), and 256 (8.1%) patients underwent AG, EF, and REBOA interventions, respectively. Therapeutic AE was performed in 690 patients who underwent AG (61.0%). The overall mortality rate was 31.4%. Multiple regression analysis identified that AG/AE (OR 0.64, 95% CI 0.52-0.80) and EF (OR 0.75, 95% CI 0.58-0.98) were significantly associated with survival, whereas REBOA (OR 4.17, 95% CI 3.00-5.82) was significantly associated with worse outcomes. CONCLUSIONS: In Japan, patients with pelvic fracture who were in shock had high mortality rates. AG/AE and EF were associated with decreased mortality. AG may benefit from the early detection of arterial bleeding, leading to decreased mortality of patients with pelvic fracture in shock.

Comparison of trauma outcomes between Japan and the USA using national trauma registries.

BACKGROUND: The National Trauma Data Bank (NTDB) has served as a global benchmark for trauma care quality and outcomes. Herein, we compared patient characteristics, trauma management, and outcomes between Japanese emergency and critical care centers and US level 1 trauma centers using the Japanese Trauma Data Bank (JTDB) and NTDB. METHODS: A retrospective cohort matching (1:1) study was performed. Patients treated in 2013 with an Injury Severity Score ≥9 were included. The primary outcome measure was in-hospital mortality. The secondary outcome measures included the hospital length of stay and the rate of use of radiological diagnostic modalities. RESULTS: A total of 14 960 pairs with well-balanced characteristics were generated from 22 535 and 112 060 eligible patients in the JTDB and NTDB, respectively. Before matching, the in-hospital mortality was higher in the JTDB than in the NTDB (7.6% vs. 6.1%; OR, 1.28; 95% CI 1.21 to 1.35). However, after matching, the in-hospital mortality was lower in the JTDB cohort (4.2% vs. 5.8%; OR, 0.72; 95% CI 0.65 to 0.80). CT scans were used in >80% of JTDB patients, which was more than 1.5 times as often as the use in the NTDB cohort. In subgroup analyses, only patients who received a blood transfusion had a poorer survival outcome in the JTDB compared with the NTDB (OR, 1.32; 95% CI 1.07 to 1.64). DISCUSSION: We observed marked differences in trauma care between Japan and the USA. Although the quality of the recent Japanese trauma care appears to be approaching that of the USA, it may be further improved, such as by the establishment of transfusion protocols. LEVEL OF EVIDENCE: Level IV.

Clinical Evaluation of "Shock Bowel" Using Intestinal Fatty Acid Binding Protein.

"Shock bowel" is one of the computed tomographic (CT) signs of hypotension, yet its clinical implications remain poorly understood. We evaluated how shock bowel affects clinical outcomes and the extent of intestinal epithelial damage in trauma patients by measuring the level of intestinal fatty acid binding protein (I-FABP). We reviewed the initial CT scans, taken in the emergency room, of 92 patients with severe blunt torso trauma who were consecutively admitted during a 24-month period. The data collected included CT signs of hypotension, I-FABP, feeding intolerance, and other clinical outcomes. Demographic and clinical outcomes were compared in patients with and without hemodynamic shock and shock bowel. Shock bowel was found in 16 patients (17.4%); of them 7 patients (43.8%) did not have hemodynamic shock. Certain CT signs of hypotension, namely free peritoneal fluid, contrast extravasation, small-caliber aorta, and shock bowel, were significantly more common in patients with hemodynamic shock than in patients without (P < 0.05). Injury severity score and the rate of consciousness disturbance were significantly higher in patients with shock bowel than in patients without (P < 0.05). The rate of feeding intolerance and median plasma I-FABP levels were significantly higher in patients with shock bowel than in patients without (75.0% vs. 22.4%, P < 0.001 and 17.0 ng/mL vs. 3.7 ng/mL, P < 0.001, respectively). There was no difference in mortality. In conclusion, shock bowel is not always due to hemodynamic shock. It does, however, indicate severe intestinal mucosal damages and may predict feeding intolerance.

Diagnostic value of intestinal fatty acid-binding protein for pneumatosis intestinalis.

BACKGROUND: Pneumatosis intestinalis (PI) is known as a sign of a life-threatening bowel ischemia. We aimed to evaluate the utility of intestinal fatty acid-binding protein (I-FABP) in the diagnosis of pathologic PI. METHODS: All consecutive patients who presented to our emergency department with PI were prospectively enrolled. The diagnostic performance of I-FABP for pathologic PI was compared with that of other traditional biomarkers and various parameters. RESULTS: Seventy patients with PI were enrolled. Pathologic PI was diagnosed in 27 patients (39%). The levels of most biomarkers were significantly higher in patients with pathologic PI than those with nonpathologic PI (P < .05). Receiver operator characteristic analysis revealed that the area under the curve (AUC) was highest for I-FABP (area under the curve = .82) in the diagnosis of pathologic PI. CONCLUSIONS: High I-FABP value, in combination with other parameters, might be clinically useful for pathologic PI.

Cardiopulmonary Resuscitation Training in Schools: A Comparison of Trainee Satisfaction among Different Age Groups.

Cardiopulmonary resuscitation (CPR) has recently been added to the school curriculum worldwide and is currently taught to students between the ages of 10 and 16 years. The effect of the age of trainees on their satisfaction with CPR training has yet been elucidated. The aim of this study was to compare the satisfaction of trainees of different ages who participated in CPR training in schools in Japan. In total, 392 primary school students (10-11 years old), 1798 junior high school students (12-13 years old), and 4162 high schools students (15-16 years old) underwent the same 3-h course of CPR training, according to the guidelines of 2000 for Emergency Cardiovascular Care and CPR. The course was evaluated by a questionnaire completed by the participants. Primary school students responded most positively to all questions, including those reflecting enjoyment and the confidence of participants to apply CPR (Jonckheere-Terpstra test: P < 0.01). Exploratory factor analysis defined three latent variables (reaction, concentration, and naïveté) based on the seven variables addressed in the questionnaire. In the causal relationships analyzed by structural equation modeling (SEM), naïveté (which is related to age) directly affected the other latent variables. The current model suggested that the students' satisfaction with CPR training was strongly related to their age. Primary school students enjoyed CPR training more and were more confident in their ability to perform CPR than junior high and high school students were. Therefore, children aged 10-11 years may be the most appropriate candidates for the introduction of CPR training in schools.

Diagnostic accuracy of oblique chest radiograph for occult pneumothorax: comparison with ultrasonography.

BACKGRAOUND: An occult pneumothorax is a pneumothorax that is not seen on a supine chest X-ray but is detected by computed tomography scanning. However, critical patients are difficult to transport to the computed tomography suite. We previously reported a method to detect occult pneumothorax using oblique chest radiography (OXR). Several authors have also reported that ultrasonography is an effective technique for detecting occult pneumothorax. The aim of this study was to evaluate the usefulness of OXR in the diagnosis of the occult pneumothorax and to compare OXR with ultrasonography. METHODS: All consecutive blunt chest trauma patients with clinically suspected pneumothorax on arrival at the emergency department were prospectively included at our tertiary-care center. The patients underwent OXR and ultrasonography, and underwent computed tomography scans as the gold standard. Occult pneumothorax size on computed tomography was classified as minuscule, anterior, or anterolateral. RESULTS: One hundred and fifty-nine patients were enrolled. Of the 70 occult pneumothoraces found in the 318 thoraces, 19 were minuscule, 32 were anterior, and 19 were anterolateral. The sensitivity and specificity of OXR for detecting occult pneumothorax was 61.4 % and 99.2 %, respectively. The sensitivity and specificity of lung ultrasonography was 62.9 % and 98.8 %, respectively. Among 27 occult pneumothoraces that could not be detected by OXR, 16 were minuscule and 21 could be conservatively managed without thoracostomy. CONCLUSION: OXR appears to be as good method as lung ultrasonography in the detection of large occult pneumothorax. In trauma patients who are difficult to transfer to computed tomography scan, OXR may be effective at detecting occult pneumothorax with a risk of progression.

Chest tube insertion direction: is it always necessary to insert a chest tube posteriorly in primary trauma care?

BACKGROUND: The advanced trauma life support guidelines suggest that, in primary care, the chest tube should be placed posteriorly along the inside of the chest wall. A chest tube located in the posterior pleural cavity is of use in monitoring the volume of hemothoraces. However, posterior chest tubes have a tendency to act as nonfunctional drains for the evacuation of pneumothoraces, and additional chest tube may be required. Thus, it is not always necessary to insert chest tubes posteriorly. The purpose of this study was to determine whether posterior chest tubes are unnecessary in trauma care. METHODS: We reviewed the volume of hemothoraces from 78 chest drains emergently placed posteriorly at a primary trauma care in 75 blunt chest trauma patients who were consecutively admitted over a 6-year period, excluding those with cardiopulmonary arrest and occult pneumothoraces. Massive acute hemothorax (MAH), in which the chest tube should be inserted posteriorly, was defined as the evacuation of more than 500 mL of blood or the need for hemostatic intervention within 24 hours of trauma admission. Demographics, interventions, and outcomes were analyzed. We also reviewed the malpositioning of 74 chest tubes based on anterior and posterior insertion directions in patients who subsequently underwent computed tomography. RESULTS: The overall incidence of MAH was 23% (n = 18). In the univariate analysis, the presence of multiple rib fractures, shock, pulmonary opacities on chest x-ray, and the need for intubation were found to be independent predictors for the development of MAH. If all 4 independent predictors were absent, none of the patients developed MAH. The incidence of nonfunctional chest drains that required reinsertion or the addition of a new drainage was 27% (n = 20). The rates of both radiologic and functional malposition in chest tubes with posterior insertion were significantly higher than in patients with anterior insertion (64% and 43% vs 13% and 6%, respectively; P < .01). CONCLUSIONS: Chest tubes did not need to be directed posteriorly in many trauma cases. Posterior chest tubes have a high incidence of being malpositioned. This malpositioning may be prevented by judging the necessity for posterior insertion.

Digital video recording in trauma surgery using commercially available equipment.

INTRODUCTION: Although videos of surgical procedures are useful as an educational tool, the recording of trauma surgeries in emergency situations is difficult. We describe an inexpensive and practical shooting method using a commercially available head-mounted video camera. METHODS: We used a ContourHD 1080p Helmet Camera (Contour Inc., Seattle, Washington, USA.). This small, self-contained video camera and recording system was originally designed for easy videography of outdoor sports by participants. RESULTS: We were able to easily make high-quality video recordings of our trauma surgeries, including an emergency room thoracotomy for chest stab wounds and a crush laparotomy for a severe liver injury. CONCLUSION: There are currently many options for recording surgery in the field, but the recording device and system should be chosen according to the surgical situation. We consider the use of a helmet-mounted, self-contained high-definition video camera-recorder to be an inexpensive, quick, and easy method for recording trauma surgeries.

Inaccuracy and misjudged factors of Glasgow Coma Scale scores when assessed by inexperienced physicians.

OBJECTIVES: Appropriate triage of a large number of patients with head injury is crucial in the emergency department (ED) as well as in the field. Traumatic brain injury (TBI) is primarily assessed using the Glasgow Coma Scale (GCS) to evaluate consciousness. However, GCS score assignment is far from sufficiently reliable for correct assessment, especially with inexperienced users. The purpose of this study was to reveal what factors are misjudged when assessed by inexperienced medical personnel. METHODS: We analyzed GCS eye, verbal, and motor response (EVM) scoring profiles conducted by postgraduate year 1 junior residents (n=94) before they began residency in specific departments. GCS assessment was tested using a video simulation that portrayed mock patients with eight different levels of consciousness that are frequently encountered in trauma patients. RESULTS: On average, 26±18% of examinees failed to provide the correct EVM profiles for the eight selected consciousness levels. Primary misjudged GCS factors belonged to two categories: the assessment of "confused conversation (V4)", and the assessment of "withdrawal motor response (M4)". CONCLUSION: Additional instruction regarding the specific misjudged factors identified in this study may help inexperienced medical personnel improve the reliability of GCS score assignment to casualties with TBI.

Predictive value of a flat inferior vena cava on initial computed tomography for hemodynamic deterioration in patients with blunt torso trauma.

BACKGROUND: We aimed to investigate the value of the diameter of the inferior vena cava (IVC) on initial computed tomography (CT) to predict hemodynamic deterioration in patients with blunt torso trauma. METHODS: We reviewed the initial CT scans, taken after admission to emergency room (ER), of 114 patients with blunt torso trauma who were consecutively admitted during a 24-month period. We measured the maximal anteroposterior and transverse diameters of the IVC at the level of the renal vein. Flat vena cava (FVC) was defined as a maximal transverse to anteroposterior ratio of less than 4:1. According to the hemodynamic status, the patients were categorized into three groups. Patients with hemodynamic deterioration after the CT scans were defined as group D (n = 37). The other patients who remained hemodynamically stable after the CT scans were divided into two groups: patients who were hemodynamically stable on ER arrival were defined as group S (n = 60) and those who were in shock on ER arrival and responded to the fluid resuscitation were defined as group R (n = 17). RESULTS: The anteroposterior diameter of the IVC in group D was significantly smaller than those in groups R and S (7.6 mm ± 4.4 mm, 15.8 mm ± 5.5 mm, and 15.3 mm ± 4.2 mm, respectively; p < 0.05). Of the 93 patients without FVC, 16 (17%) were in group D, 14 (15%) required blood transfusion, and 8 (9%) required intervention. However, of the 21 patients with FVC, all patients were in group D, 20 (95%) required blood transfusion, and 17 (80%) required intervention. The patients with FVC had higher mortality (52%) than the other patients (2%). CONCLUSION: In cases of blunt torso trauma, patients with FVC on initial CT may exhibit hemodynamic deterioration, necessitating early blood transfusion and therapeutic intervention.

A comparison of Ringer's lactate and acetate solutions and resuscitative effects on splanchnic dysoxia in patients with extensive burns.

We compared the effects of Ringer's lactate (RL) and acetate (RA) solutions on parameters of splanchnic dysoxia such as PgCO(2) (PCO(2) of gastric mucosa) and pH(i) (pH of gastric mucosa) using a gastric tonometer, in addition to blood markers such as the serum arterial level of lactate, base excess, ketone body ratio, and antithrombin during the first 72h of the resuscitation period in patients with burns covering 30% or more of their body surface. A prospective study was conducted in the university tertiary referral centers. There were no significant differences in the average age, TBSA (total burn surface area), and resuscitative fluid volume during the first and second 24h between the two groups. In the RA group, PCO(2) gap values calculated employing the formula: PgCO(2)-PaCO(2) (arterial PCO(2)), and pH gap calculated by: pH(a) (arterial pH)-pH(i), improved to the normal ranges at 24 h postburn, which was significantly faster than in the RL group. On the other hand, there were no significant differences in blood parameters between the two groups over the course. These results suggest that fluid resuscitation with RA may more rapidly ameliorate splanchnic dysoxia, as evidenced by gastric tonometry, compared to that with RL.

Recombinant human interleukin-1alpha increases serum albumin, Gc-globulin, and alpha1-antitrypsin levels in burned mice.

The response to thermal injury is a complex physiologic process requiring communication between sites of injury and distant target organs. The liver, one of these target organs, synthesizes a family of secretory proteins, the acute phase proteins, that carries out specific immunoprotective functions. In this study we investigated the effects of daily recombinant human interleukin-1alpha (rhIL-1alpha) administration on the serum levels of negatively regulated, i.e., albumin and Gc-globulin and positively regulated, i.e., alpha1-antitrypsin, acute phase proteins in a murine model of thermal injury. Adult CF-1 female mice underwent a 6.5-seconds, 20% total burn surface area, full thickness steam injury, and received either intraperitoneal rhIL-1alpha (20 microg x kg(-1) x day(-1)) or diluent for 10 days. Seven and 14 days after injury, mice were sacrificed, and serum albumin, Gc-globulin and alpha1-antitrypsin levels were measured by crossed immunoelectrophoresis technique. Thermal injury significantly lowered serum albumin levels, tended to decrease Gc-globulin levels, and increased serum alpha1-antitrypsin levels. Daily rhIL-1alpha administration after burn injury prevented hypoalbuminemia, and increased serum levels of Gc-globulin and alpha1-antitrypsin. IL-1 therapy might be helpful to maintain the homeostasis and immunity of the host after thermal injury.