Routine Head Computed Tomography for Patients in the Emergency Room with Trauma Requires Both Thick- and Thin-Slice Images.

Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8-10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures. Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays (n = 410). Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals (p = 0.048). Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault.

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.

Feasibility study of immediate pharyngeal cooling initiation in cardiac arrest patients after arrival at the emergency room.

AIM: Cooling the pharynx and upper oesophagus would be more advantageous for rapid induction of therapeutic hypothermia since the carotid arteries run in their vicinity. The aim of this study was to determine the effects of pharyngeal cooling on brain temperature and the safety and feasibility for patients under resuscitation. METHODS: Witnessed non-traumatic cardiac arrest patients (n=108) were randomized to receive standard care with (n=53) or without pharyngeal cooling (n=55). In the emergency room, pharyngeal cooling was initiated before or shortly after return of spontaneous circulation by perfusing physiological saline (5 °C) into a pharyngeal cuff for 120 min. RESULTS: There was a significant decrease in tympanic temperature at 40 min after arrival (P=0.02) with a maximum difference between the groups at 120 min (32.9 ± 1.2°C, pharyngeal cooling group vs. 34.1 ± 1.3°C, control group; P<0.001). The return of spontaneous circulation (70% vs. 65%, P=0.63) and rearrest (38% vs. 47%, P=0.45) rates were not significantly different based on the initiation of pharyngeal cooling. No post-treatment mechanical or cold-related injury was observed on the pharyngeal epithelium by macroscopic observation. The thrombocytopaenia incidence was lower in the pharyngeal cooling group (P=0.001) during the 3-day period after arrival. The cumulative survival rate at 1 month was not significantly different between the two groups. CONCLUSIONS: Initiation of pharyngeal cooling before or immediately after the return of spontaneous circulation is safe and feasible. Pharyngeal cooling can rapidly decrease tympanic temperature without adverse effects on circulation or the pharyngeal epithelium.

Clinical characteristics of redback spider bites.

BACKGROUND: Redback spiders (Latrodectus hasselti) (RBSs) are venomous spiders that have recently spread to Asia from Australia. Since the first case report in 1997 (Osaka), RBS bites have been a clinical and administrative issue in Japan; however, the clinical characteristics and effective treatment of RBS bites, particularly outside Australia remains unclear. This study aimed to elucidate the clinical characteristics of RBS bites and to clarify the effectiveness of the administration of antivenom for treatment. METHODS: We performed a retrospective questionnaire survey from January 2009 to December 2013 to determine the following: patient characteristics, effect of antivenom treatment, and outcomes. To clarify the characteristics of patients who develop systemic symptoms, we compared patients with localized symptoms and those with systemic symptoms. We also examined the efficacy and adverse effects in cases administered antivenom. RESULTS: Over the 5-year study period, 28 patients were identified from 10 hospitals. Of these, 39.3% were male and the median age was 32 years. Bites most commonly occurred on the hand, followed by the forearm. Over 80% of patients developed local pain and erythema, and 35.7% (10 patients) developed systemic symptoms. Baseline characteristics, vital signs, laboratory data, treatment-related factors, and outcome were not significantly different between the localized and systemic symptoms groups. Six patients with systemic symptoms received antivenom, of whom four experienced symptom relief following antivenom administration. Premedication with an antihistamine or epinephrine to prevent the adverse effects of antivenom was administered in four patients, which resulted in no anaphylaxis. One out of two patients who did not receive premedication developed a mild allergic reaction after antivenom administration that subsided without treatment. CONCLUSIONS: Approximately one third of cases developed systemic symptoms, and antivenom was administered effectively and safely in severe cases. Further research is required to identify clinically applicable indications for antivenom use.

High energy trauma patients treated in the department of general surgery in a secondary emergency facility in Japan.

OBJECTIVE: We clarified the characteristics of the high energy trauma patients that entered the general surgery ward of Fukuoka city hospital (FCH), a 200 bed secondary emergency hospital in Japan. PATIENTS AND METHODS: Of the 7,826 total ambulance cases treated from April 2008 to March 2012 in our emergency room, 831 trauma patients who entered our hospital were analyzed. These patients were classified into a non high energy (NHE) and high energy trauma (HE) group based on the mechanisms of injuries. RESULTS: Of the 831 trauma cases, 741 (89.2%) were in the NHE and 90 (10.8%) were in the HE group. Eleven of the 741 cases (1.5%) in the NHE group and 18 of the 90 cases (20.0%) in the HE group entered the Department of General Surgery as inpatients, with the frequency being significantly higher in the latter group (p < 0.01). 11 of the 18 cases (61.1%) of Department of General Surgery in the HE group were diagnosed to have an injury severity score (ISS) of 15 or higher, and the rate of preventable trauma deaths (PTDs) of those 11 cases was 9.1% (1/11). CONCLUSIONS: The proportion of the patients that entered the Department of General Surgery was higher in the HE group than in the NHE group. The surgical departments of secondary emergency facilities are expected to contribute to the local trauma emergency systems.

The practice of emergency medicine in Fukuoka City Hospital, a secondary emergency facility in Japan.

OBJECTIVE: The transition of emergency departments and the current situation of emergency medicine (EM) in Fukuoka City Hospital (FCH) were reviewed. METHODS: The data concerning emergency medicine, such as the transition of intra-hospital emergency systems, were obtained from annual reports published in our hospital. Additionally, the data regarding educational programs for emergency room staff, the number of patients taken to the emergency room by ambulances, the activities regarding the Fukuoka Medical Rally (FMR) and the disaster relief team (DRT) were also reviewed and analyzed. RESULTS: Departments of neurology, neurosurgery, emergency, and cardiology were opened sequentially, starting in 2003, with an establishment of facilities of an emergency room (ER), intensive care unit (ICU), stroke care unit (SCU), and coronary care unit (CCU). Regarding educational programs, lectures and demonstrations on basic and advanced life support techniques were given to all staff annually starting in 2004, and resident doctors completed rotations in the ER and the ICU for three months. FCH staff consistently obtained excellent results at the FMR. Ambulance crews attended lectures and received training on EM and intra-tracheal intubation. The numbers of patients taken by ambulance to FCH increased from 129 in 2002 to 2,316 in 2011. The DRT was dispatched to respond to disasters that occurred in Japan. CONCLUSIONS: As a secondary emergency hospital, FCH has developed a system to accept emergency patients. This project will contribute to the improvement of the EM system in the area.

A method to detect occult pneumothorax with chest radiography.

Small pneumothoraces are often not visible on supine screening chest radiographs because they develop anteriorly to the lung. These pneumothoraces are termed occult. Occult pneumothoraces account for an astonishingly high 52% to 63% of all traumatic pneumothoraces. A 19-year-old obese woman was involved in a head-on car accident. The admission anteroposterior chest radiographs were unremarkable. Because of the presence of right chest tenderness and an abrasion, we suspected the presence of a pneumothorax. Thus, we decided to take a supine oblique chest radiograph of the right side of the thorax, which clearly revealed a visceral pleural line, consistent with a diagnosis of traumatic pneumothorax. A pneumothorax may be present when a supine chest radiograph reveals either an apparent deepening of the costophrenic angle (the "deep sulcus sign") or the presence of 2 diaphragm-lung interfaces (the "double diaphragm sign"). However, in practice, supine chest radiographs have poor sensitivity for occult pneumothoraces. Oblique chest radiograph is a useful and fast screening tool that should be considered for cases of blunt chest trauma, especially when transport of critically ill patients to the computed tomographic suite is dangerous or when imminent transfer to another hospital is being arranged and early diagnosis of an occult pneumothorax is essential.

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.

Does splenic preservation treatment (embolization, splenorrhaphy, and partial splenectomy) improve immunologic function and long-term prognosis after splenic injury?

BACKGROUND: : To assess the immunologic alteration and long-term prognosis after splenic injury from preservation treatment (PT) (embolization, splenorrhaphy, partial splencetomy) and to compare with splenectomy (SN). METHODS: : The long-term prognosis of patients with blunt splenic injury treated at seven tertiary emergency centers in Japan was retrospectively studied. Patients were followed up by telephone interview and written questionnaire. Blood samples and abdominal computer tomography scans were taken from patients who consented, and immunologic indices and the remaining volume of the spleen were measured. RESULTS: : There was no episode of severe infection requiring hospitalization among the 66 SN patients (760 patient-year) and the 34 PT (213 patient-year) patients. Blood tests from 58 patients (24 SN vs. 34 PT) revealed significant differences in platelet count, Howell-Jolly body positive rate (SN 87% vs. PT 3%), white blood cells, total lymphocyte count, T-cell count, B-cell count, and serum IgG level. There was no significant difference in serum levels of IgM or specific IgG antibodies against 14 types of Streptococcus pneumoniae capsular polysaccharide, C3, C4, high-sensitivity C-reactive protein, and B -cell subset (surface marker immunoglobulins: IgA, IgG, and IgM). Most patients had anti-S. pneumoniae antibody levels less than that of the reference level for multiple serotypes (average 3 in SN and 4 in PT). A computer tomography scan was taken from 33 PT patients; the volume of spleen remaining averaged 130 mL (range, 48-287 mL). CONCLUSION: : PT did not show discernible advantage over SN in immunologic indices including IgM and 14 serotypes of anti-S. pneumoniae antibodies, suggesting prophylactic measures and close follow-up are necessary after PT and SN.