Use of preoperative contrast-enhanced computed tomography in damage control strategy for blunt liver injury: A case report.

For patients with unstable abdominal trauma unresponsive to initial transfusion, the damage control strategy includes prompt hemostasis by open surgery and packing. Recently, a hybrid treatment that combines packing and transcatheter arterial embolization as a damage control strategy was reported to be effective; however, the indications and techniques are yet to be established. A 25-year-old male patient who was in shock due to severe liver injury after a traffic accident was brought to our emergency room by emergency services. After initial resuscitation, including resuscitative endovascular balloon occlusion of the aorta and blood transfusion, preoperative contrast-enhanced computed tomography indicated grade IV liver injury with active bleeding from the right hepatic artery. Damage control strategy with packing and subsequent transcatheter arterial embolization was determined to be useful. During treatment, bile leakage was observed. An endoscopic nasobiliary drainage tube was inserted, and the patient was treated conservatively. He was discharged on day 83 of hospitalization. Although using preoperative contrast-enhanced computed tomography before damage control surgery remains controversial, it can provide useful information to determine damage control strategy, including morphological evaluation of the injured area and the presence of active bleeding.

Damage Control Management for Thoracic Trauma with Cardiac Arrest Complicated by Emphysematous Gastritis and Cystitis.

A 78-year-old man was found unconscious after sliding from a rock. His history included hypertension, atrial fibrillation and cerebral infarction requiring warfarin. On arrival, he received six units of blood type O transfusion and vitamin K in an emergency room (ER) due to hemorrhagic shock. His systolic blood pressure temporarily increased to 100 mmHg, and he underwent traumatic pan scan revealing occipital fracture, cerebral contusion, and cervical and multiple left rib fractures with left-dominant bilateral hemothorax. He re-entered a shock state after the examination and underwent transfusion again, but he then entered cardiac arrest. He underwent damage control surgery in the ER and obtained spontaneous circulation. The postoperative course was eventful, but he eventually obtained a survival outcome. Damage control surgery may be beneficial, even in cases of severe thoracic blunt trauma; however, postoperative infections may cause severe problems.

Corticosteroid treatment for early acute respiratory distress syndrome: a systematic review and meta-analysis of randomized trials.

BACKGROUND: The effect of corticosteroid treatment on survival outcome in early acute respiratory distress syndrome (ARDS) is still debated. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the efficacy of prolonged corticosteroid therapy in early ARDS. METHODS: We assessed the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases from inception to August 1, 2020. We included RCTs that compared prolonged corticosteroid therapy with control treatment wherein the intervention was started within 72 h of ARDS diagnosis. Two investigators independently screened the citations and conducted the data extraction. The primary outcomes were all-cause 28- or 30-day mortality and 60-day mortality. Several endpoints such as ventilator-free days and adverse events were set as the secondary outcomes. DerSimonian-Laird random-effects models were used to report pooled odds ratios (ORs). RESULTS: Among the 4 RCTs included, all referred to the all-cause 28- or 30-day mortality. In the corticosteroid group, 108 of 385 patients (28.1%) died, while 139 of 357 (38.9%) died in the control group (pooled OR, 0.61; 95% confidence interval [CI], 0.44-0.85). Three RCTs mentioned the all-cause 60-day mortality. In the corticosteroid group, 78 of 300 patients (26.0%) died, while 101 of 265 (38.1%) died in the control group (pooled OR, 0.57; 95% CI, 0.40-0.83). For secondary outcomes, corticosteroid treatment versus control significantly prolonged the ventilator-free days (4 RCTs: mean difference, 3.74; 95% CI, 1.53-5.95) but caused hyperglycemia (3 RCTs: pooled OR, 1.52; 95% CI, 1.04-2.21). CONCLUSIONS: Prolonged corticosteroid treatment in early ARDS improved the survival outcomes. TRIAL REGISTRATION: PROSPERO, CRD42020195969.

An analysis of patients evacuated by a civilian physician-staffed helicopter from a military base.

Objective: We herein report our analysis of patients evacuated by a physician-staffed helicopter (doctor helicopter; DH) from a Japan Self Defense Force (JSDF) base. Methods: From March 2004 to November 2018, a medical chart review was retrospectively performed for all patients who were transported by a DH from the temporary heliport at the JSDF Fuji base. The subjects were divided into two groups: the Before-2013 group (n=6) and the After-2013 group (n=7). Results: The rate of military-patient involvement and the heart rate of the After-2013 group were greater than those of the-Before 2013 group, and the percutaneous oxygen saturation in the After-2013 group was lower than the Before-2013 group. Furthermore, the Glasgow Coma Scale in the After-2013 group was significantly lower than in the Before-2013 group. The survival rate was not significantly different between the two groups. Conclusion: Patients transported by DHs in the After-2013 group tended to be in more severe conditions than those transported in the Before-2013 group. This might be due to the fact that over time, the fire department, or JSDF, began to appreciate the useful role played by the DH in life-saving management.

Mountain sickness with delayed signal changes in the corpus callosum on magnetic resonance imaging: a case report.

A 32-year-old man started building a wooden desk atop Mount Fuji at an altitude of 3,776 m. Over the course of the second day, he developed lassitude and cough and experienced a headache that night; however, he continued to work. He was transported to our hospital with an altered level of consciousness. On arrival, chest radiography revealed increased opacities in both lungs, and magnetic resonance imaging (MRI) revealed a high-intensity signal in the splenium on diffusion-weighted imaging. He received mechanical ventilation following tracheal intubation. His respiratory function improved, and he was extubated on the fourth hospital day. Physical examination showed no motor weakness, and although he responded to verbal commands, he was unable to speak and was unresponsive to visual stimulation. On the seventh hospital day, head MRI showed improvement in the lesion in the splenium, although other signal changes were observed in the body of the corpus callosum. His verbal responsiveness and voice volume improved on a daily basis. Two months after the incident, he continued to experience mild recent memory disturbance. The patient described in this case report showed delayed signal changes in the body of the corpus callosum, possibly secondary to the onset of microbleed-induced edema.

Experience using a portable X-ray system at the scene transported by a physician-staffed helicopter.

BACKGROUND: Fujifilm (Tokyo, Japan) developed a portable X-ray system called the CALNEO Xair, which can be carried by a physician. The X-ray radiation machine weighs 3.5 kg. The dimensions are: height, 144 mm; length, 148 mm; width, 258 mm. CASE PRESENTATION: When a 33-year-old woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. Staff of the doctor helicopter checked her at the scene, and the findings of chest and pelvic X-ray were all negative. She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance. CONCLUSION: This is the first report of a case evaluated by a portable X-ray system at the scene, under transportation by a doctor helicopter. This system could be useful for undertaking prehospital assessment and medical treatment.

The Significance of a Cooperative Medical System for Treating Decompression Illness on the Izu Peninsula in Japan.

INTRODUCTION: In 2011, our hospital on the Izu peninsula began to hold meetings to discuss how to manage patients with decompression illness (DCI) to establish a cooperative medical system. We retrospectively investigated the influence of these meetings and the changes subsequently effected. METHODS: A medical chart review was retrospectively performed to investigate all cases between January 2005 and December 2017 in which the transport of patients with DCI via a physician-staffed helicopter emergency medical service (HEMS) was attempted. The patients were divided into 2 groups: the preprogram group and the postprogram group. RESULTS: There were 63 patients in the preprogram group and 65 in the postprogram group. There were no cases in which a patient's symptoms deteriorated during transportation by the HEMS. The frequency of dispatch to the scene for direct evacuation in the postprogram group (86%) was greater than that in the preprogram group (74%), but the difference was not statistically significant (P=0.09). In the postprogram group, the duration of activities at the scene or the first aid hospital was significantly shorter in comparison to the preprogram group (P=0.01). CONCLUSIONS: This retrospective study revealed simultaneity between the introduction of the yearly meetings and a reduced duration of the HEMS staff's activity at either the scene or the first aid hospital.

Decrease in Butyrylcholinesterase Accompanied by Intermediate-like Syndrome after Massive Ingestion of a Glyphosate-surfactant.

An 86-year-old woman intentionally drank approximately 300 mL of a glyphosate-surfactant. She was found with consciousness disturbance and experienced several vomiting episodes. On arrival, serum biochemistry revealed a decreased level of butyrylcholinesterase (B-CHE) [11 (normal range: 180-450) IU/L]. Later, her B-CHE level further decreased to single-digit values, and she became comatose with involuntary movement and an increase in muscle tone. Her consciousness level and muscle tone improved with the recovery of her B-CHE level. Physicians should be alert for the occurrence of intermediate syndrome when the B-CHE levels of patients who have consumed a massive amount of glyphosate-surfactant show a prolonged decrease.

The Utility of a Portable X-ray System.

Fujifilm (Tokyo, Japan) developed a portable X-ray system called the CALNEO Xair. We herein report our experience in using this portable X-ray system at the scene after transportation by a doctor helicopter (DH). An explosion suddenly occurred while a 42-year-old man was handling toluene in a factory, causing his clothes to catch on fire. When the staff of a physician-staffed helicopter (DH) equipped with a portable X-ray system checked the man at the rendezvous point, he had second- and third-degree flame burns to > 70% of his total body surface area. A chest X-ray obtained using the portable X-ray system showed clear lung fields. A noninvasive carboxyhemoglobin monitor indicated a carboxyhemoglobin value of 6%. He was transferred to a special burn center by the DH. This is the first reported case in which a portable X-ray system was used to evaluate blast injuries in the prehospital setting. This system may be useful for performing prehospital medical treatment for blast injury victims.

A Smartphone Video Transmission System for Verification of Transfusion.

A physician-staffed helicopter emergency medical service called a doctor helicopter (DH) in Eastern Shizuoka was equipped with a smartphone video transmission system in April 2018. We herein report on the introduction of this system for the verification of transfusion in the DH. A 51-year-old man visited a local hospital after cutting his left neck himself. He was diagnosed with jugular vein injury and underwent compressive hemostasis. As he entered profound hemorrhagic shock, he underwent tracheal intubation, massive fluid resuscitation, and administration of 3 vasopressor agents to maintain circulation. The Eastern Shizuoka DH was requested to transport this patient. After making contact with the patient, the staff of the DH started prehospital transfusion. Because this was the first case of transfusion in a prehospital setting for our hospital, we held a meeting in which we used a smartphone video transmission system to verify the condition surrounding the transfusion in the DH. By reviewing the video record, we confirmed that the transfusion was performed safely and correctly in the prehospital setting. This smartphone video transmission system was useful for verifying the activity of the staff in the DH.

A Case in Which Focal Convulsion Was the Initial Sign of Fatal Aortic Dissection.

Focal convulsion as an initial sign of aortic dissection is extremely rare. Type A aortic dissection involves the aortic arch, which may result in seizure either through the extension of the dissection into the common carotid arteries or through thromboembolism or cerebral hypoperfusion. Physicians should perform whole body computed tomography to determine whether or not dissection is present when treating patients with convulsion and a high level of fibrin degradation products.

Fatal Acute Myocardial Infarction after Multiple Blunt Injuries Involving the Chest.

The patient was a 60-year-old male fell whose head and left chest hit the ground after falling from a height of 2 m. He complained of the left shoulder and chest pain after regaining consciousness. On arrival, he showed left bloody otorrhea, left chest tenderness, and a limited range of motion due to the left shoulder pain. Emergency chest roentgenography revealed multiple left rib fractures, left clavicular fracture with decreased radiolucency in the left lung field, suggesting lung contusion. When the patient was being transported for computed tomography, he suddenly displayed ventricular tachycardia with pulse and subsequently became VF storm, which required percutaneous cardiopulmonary support. The coronary angiogram showed complete obstruction of the branch of the anterior descending artery. Coronary angioplasty resulted in recanalization; however, massive hemorrhage from the left ear was recognized. Computed tomography revealed traumatic subarachnoid hemorrhage and left massive hemothorax requiring thoracostomy. Massive hemorrhage from the left ear and left thoracic cavity continued after the patient was transported to the coronary care unit. He underwent massive transfusion; however, he died on the same day.

A Report Concerning Collaboration Between a Physician-staffed Helicopter (Doctor Helicopter) and Firefighting/Rescue Helicopter.

OBJECTIVE: In Japan, the main helicopters that transport patients are physician-staffed helicopters (known as doctor helicopters [DHs]) and firefighter/rescue helicopters (F/RHs). We report the collaboration between F/RHs and DHs in eastern Shizuoka Prefecture. METHODS: We retrospectively investigated all of the patients who were transported by F/RHs in Shizuoka Prefecture between January 2015 and April 2018. RESULTS: Nine cases were defined as subjects. Seven subjects had suffered trauma, 1 decompression illness, and 1 intrinsic disease. Seven of the 9 subjects were rescued from the bottom of a cliff or shore reef, and all 7 were transferred from an F/RH to a DH at the rendezvous zone near the rescue scene. One of the 9 subjects was a mass casualty event, and the remaining patient was rescued and directly transported to our hospital by an F/RH. All but 1 who was in cardiac arrest at the scene survived. CONCLUSION: Because relatively few subjects were managed via collaboration between an F/RH and a DH in eastern Shizuoka Prefecture, further studies will be required to investigate whether or not such a collaboration is useful for improving the outcome of sick and wounded patients.