Hypothermia does not hasten death during uncontrolled hemorrhagic shock presenting as the "triad of death" in rats.

Aim: The aim of this study was to investigate the effect of hypothermia on survival and coagulopathy in hemorrhagic shock presenting as the "triad of death". Methods: Sixteen rats were lightly anesthetized with halothane while maintaining spontaneous breathing. The triad of death was simulated by inducing hypothermia (32.0°C) with surface body cooling and hemodilution with replacement of 20 mL blood with 50 mL normal saline. Then, rats were randomly assigned to one of two rectal temperature groups (n = 8/group: group 1, rewarming to 37.0°C; group 2, maintenance at 32.0°C) and subjected to hemorrhagic shock initiated by amputation of the tail at 75% of its length. The rats were then observed for survival time without fluid resuscitation. Blood coagulability with Sonoclot analysis was also assessed. Results: The triad of death status was considered as being induced at a rectal temperature of 32°C, arterial pH of 7.22, and deteriorating coagulating values. At 45 min after randomization, Sonoclot analysis revealed prolonged activated clotting times of 355 ± 131 s and "time to peak" of 23 ± 9 min in group 2, compared to 228 ± 64 s and 12 ± 1 min (P < 0.05) in group 1, respectively. Kaplan-Meier curves showed longer survival in group 2 than group 1 (P = 0.06). Conclusions: Compared to rewarming, hypothermia aggravates coagulation parameters, but does not hasten death during untreated hemorrhagic shock presenting as the triad of death.

Hemodilution as a result of aggressive fluid resuscitation aggravates coagulopathy in a rat model of uncontrolled hemorrhagic shock.

BACKGROUND: The relationship between dilution caused by fluid resuscitation and blood coagulability during ongoing, uncontrolled hemorrhagic shock (UHS) remains unclear. We hypothesized that dilution caused by fluid resuscitation may impair blood coagulability in UHS. METHODS: Eighteen rats underwent under halothane anesthesia. The UHS model consisted of the following phases: (1) an initial blood withdrawal of 2.5 mL per 100 g during 15 minutes, followed by UHS via tail amputation and fluid resuscitation with lactated Ringer's (LR) solution (0-60 minutes); (2) hemostasis and reinfusion of withdrawn blood and additional LR solution (60-100 minutes); and (3) observation of awake rats for 72 hours. Rats were randomized into three resuscitation regimens (n = 6 per group) during Phase I. LR solution was infused at a rate of 0.1 mL/min in Group 1, 0.25 mL/min in Group 2, and 0.75 mL/min in Group 3. Blood coagulability was assessed with a Sonoclot analysis, and survival to 72 hours were compared between groups. RESULTS: Both resuscitation regimens of Groups 2 and 3 increased the blood pressure and bleeding volume from the tail stump compared with Group 1 (p < 0.05). At the end of Phase I, the hematocrit decreased to 29% (3%) in Group 1, 23% (3%) in Group 2, and 12% (3%) in Group 3 (p < 0.05). Sonoclot analysis revealed a decreased clot rate of 16 (9) clot signal per minute in Group 2 and 14 (10) clot signal per minute in Group 3 compared with Group 1 (40 [10] clot signal per minute; p < 0.01). There was a significant correlation between clot rate and hematocrit values (r = +0.67, p < 0.01). Compared with Group 1, survival improved in Groups 2 and 3 (p < 0.05). CONCLUSION: In a rat model of UHS, aggressive fluid resuscitation aggravated hemodilution and blood coagulability as well as and bleeding but improved the hemodynamics and survival. There was a positive correlation between hemodilution and coagulation indexes. Hemodilution, as part of fluid therapy, may affect coagulopathy in UHS.

A case of successful treatment of a patient with hyperglycemia of 2700 mg/dL.

A 34-year-old man with obesity who was an avid consumer of soft drinks was found in a coma after complaining of a poor physical condition for a few days. On arrival, he had hyperglycemia of 2700 mg/dL, coma, shock, sepsis, aspiration pneumonia, acute renal failure, acute pancreatitis, liver dysfunction, and systemic mycosis. The rapid infusion of a large volume of isotonic saline, insulin, antibiotics, and ulinastatin was performed, and mechanical ventilation was applied. The treatment was complicated by transient hypernatremia resulting from osmostasis, which gradually decreased. He demonstrated transient decerebrate posturing upon stimulation; however, he became conscious within a week of admission, and his associated diseases also improved. After correcting his hyperglycemia, the patient was discharged on foot. We report our case of a patient with hyperglycemia of 2700 mg/dL, which was the highest value reported in the English literature. During the correction of the hyperglycemia, transient hypernatremia occurred to prevent abrupt decrease in osmolality, which thus resulted in cell swelling.

Hypothermia reduces resuscitation fluid volumes required to maintain blood pressure in a rat hemorrhagic shock model.

OBJECTIVE: To examine the hypothesis that resuscitative hypothermia would (1) reduce fluid requirements and reactive oxygen species production during a period of resuscitation and (2) improve survival after hemorrhagic shock (HS) in rats. METHODS: Sixteen rats underwent an HS phase (phase I: 0-75 minutes), with pressure-controlled HS at a mean arterial pressure of 30 mm Hg ± 5 mm Hg; a resuscitation phase (phase II: 75-150 minutes), with fluid resuscitation to maintain mean arterial pressure ≥75 mm Hg; and an observation phase (phase III: from 150 minutes to 72 hours). During phase II, eight rats were randomized into a normothermia group (group 1: 38°C) or a hypothermia group (group 2: 34°C). Fluid requirements during phase II and survival at 72 hours were compared between groups. Plasma levels of Vitamin E and %coenzyme Q9 (%CoQ9) were also assessed. RESULTS: The fluid requirement during resuscitation in phase II was 8.2 ± 1.4 mL/100 g in group 1 versus 2.1 mL/100 g ± 0.7 mL/100 g in group 2 (p < 0.01). Vitamin E level decreased to 10.8 µmol/L ± 1.8 µmol/L during HS in all rats. After resuscitation, it was restored to a baseline level of 15.9 µmol/L ± 3.1 µmol/L in group 2 but remained at 10.2 µmol/L ± 0.8 µmol/L in group 1 (p < 0.05). %CoQ9 did not differ significantly between the groups. At 72 hours, six of eight rats in group 1, and all rats in group 2 survived (NS). CONCLUSION: In a rat HS model, hypothermia during resuscitation from HS reduces resuscitation fluid volume required to maintain blood pressure and restores Vitamin E to the baseline level, and appears to have no adverse impact on long survival after HS.

[Investigation of the Hounsfield number of drugs in stomach using computed tomography in vitro].

BACKGROUND: A high density area (HDA) that may represent ingested drugs was detected in the stomach of a patient with a drug overdose (OD) by computed tomography (CT). However, there is no prior evidence that drugs can be visualized as an HDA by abdominal CT. We investigated whether drugs can be imaged as an HDA by CT. METHODS: Ten tablets, 5 tablets, 1 tablet and 0.1 tablet of either Solanax (0.4 mg) or Depas (0.5 mg) or Tryptanol (10 mg) or Paxil (10 mg) or Wintermin (25 mg) or Phenobal (30 mg) or Hiberna (25 mg) were each added to 10 ml of artificial gastric juice. We then measured the Hounsfield numbers immediately after mixing, 1 hour later and 7 hours later using CT images. RESULTS: All of the drugs precipitated in the artificial gastric juice and these precipitations were imaged as HDAs over 100 Hounsfield units. Moreover, the drugs maintained high Hounsfield numbers after 7 hours although there was a trend to decrease sequentially. CONCLUSION: We demonstrated that the precipitated drugs in the artificial gastric juice could be imaged as HDAs by CT.

Usefulness of computed tomography in the diagnosis of an overdose.

Computed tomography (CT) is superior for the detection of substances with low radiolucency in comparison with abdominal roentgenograms. In the present study, medical chart review was retrospectively performed for patients who were admitted and underwent plain CT including the stomach on arrival to investigate whether CT is useful for diagnosing overdose (OD). The subjects were divided into patients with OD who did not undergo gastric lavage (OD group) and those without OD (Control group). The presence of a radiopaque area (Hounsfield number over 100 on a range of interest of 3 mm2) in the stomach on CT was defined as a positive finding. The average Glasgow Coma Scale in the OD group (n=11) was significantly lower than that in the Control group (n=137). Positive findings on CT were found more frequently in the OD group than in the Control group (100 vs. 19.7%, p＜0.0001). Based on the finding of a high-density deposition in the bottom of the stomach, the CT predicted OD with 98.5% specificity. Accordingly, CT findings of a high-density deposition in the stomach of a patient with a diminished consciousness may suggest the presence of a recent overdose.

A case of thoracic degloving injury with flail chest.

A 75-year-old male patient suffered a chest degloving injury when he fell on his back and was run over by a small farm tractor he was pulling. At the time of patient admission, the paradoxical motion of the right chest wall was remarkable; and he had an open fracture of the right humerus, a dislocation of the right ankle, and a laceration of the right forearm. Chest computed tomography revealed fractures of the fifth to seventh ribs and detachment of both the right pectoralis major muscle and serratus anterior muscle from the chest wall, with a disconnected right thoracic cavity. Because the right flail chest was severe and there was a large amount of air leakage that continued under positive-pressure ventilation for pneumatic stabilization, we performed surgical fixation of the ribs and repaired the lung injury on the fifth hospital day. The patient's postoperative course was uneventful.

Effects of arterial oxygen content on oxidative stress during resuscitation in a rat hemorrhagic shock model.

OBJECTIVE: To examine whether reactive oxygen species (ROS) production is affected by arterial oxygen content (CaO(2)) in attempted resuscitation to restore blood pressure from hemorrhagic shock (HS) or not. METHODS: Under light anesthesia and spontaneous beating, 16 rats underwent HS for 80min, during which 3.0mL/100g of blood was withdrawn, followed by resuscitation attempt for 70min. At 80min, rats were randomized into a high-CaO(2) group (Group 1, transfusion under fractional inspired oxygen (F(I)O(2)) of 1.0, n=8) or a low-CaO(2) group (Group 2, fluid administration under F(I)O(2) of 0.21, n=8). In each group, either blood or lactate Ringer's (LR) solution was infused to maintain mean arterial pressure ≥75mmHg under each F(I)O(2) concentration. CaO(2), O(2) utilization coefficient (UC) and plasma %CoQ9 were compared between groups. RESULTS: Mean infused volume for attempted resuscitation was 7.6±1.0mL of blood in Group 1, and 31.4±5.5mL of LR solution in Group 2. At the end of resuscitation, CaO(2) was 18.5±1.2 vol% in Group 1, almost double the 9.1±0.8 vol% in Group 2 (P<0.01). O(2) UC and %CoQ9 in all rats increased from baselines of 0.25±0.12 and 7.6±1.8% to 0.44±0.13 and 9.7±1.8% after resuscitation, respectively (P<0.05 vs. baseline for each), but did not differ significantly between the groups. CONCLUSION: In a rat HS model, attempted resuscitation to restore blood pressure increased O(2) UC as well as %CoQ9. However, the magnitude of %CoQ9 increase that represents ROS production is not affected by CaO(2) during resuscitation from HS.

[Transient bilateral complete blindness and severe abdominal pain in a patient with alcoholic ketoacidosis].

A 66-year-old man presented with bilateral complete blindness and severe abdominal pain. He was diagnosed with ethanol-induced severe ketoacidosis and septic shock and dopamine and sodium bicarbonate was administered to him. This treatment rapidly ameliorated his symptoms of blindness and abdominal pain. It should be noted that alcoholic ketoacidosis (AKA) may induce severe acidosis and hypotension, leading to transient blindness,which is a condition that can be cured by appropriate treatment.

[Case of gluteal compartment syndrome associated with bilateral sciatic nerve palsies].

A patient presented with a rare case of bilateral gluteal compartment syndrome. A 39-year-old male, who experienced unconsciousness in a sitting position attributable to a drug overdose, suffered from right dominant bilateral gluteal compartment syndrome with bilateral leg paralysis due to sciatic nerve palsy, involving rhabdomyolysis and acute renal failure. Since the pressure in the right gluteus maximus compartment in the buttocks was recorded as 20 mmHg, he was administered conservative treatment. Within 12 months, he recovered his ability to walk; however, right foot paralysis and right sciatic nerve irritation were observed to persist.

A case of takotsubo cardiomyopathy associated with Kounis syndrome.

A sixty-five-year old female, with a past history of variant angina and asthma, collapsed after complaining of chest pain and regained spontaneous circulation by resuscitation. An electrocardiograph showed a QS pattern on the precordial leads and sonography revealed a takotsubo cardiomyopathy-like movement. During induced hypothermic therapy for protection of her brain and heart using a drug which dilated the coronary artery, she collapsed again with ventricular flatter for 40 min; however, she re-obtained return of spontaneous circulation and eventually regained consciousness. After correction of eosinophilia by steroids, the variant angina with life-threatening arrhythmia and asthma attack subsided. She was discharged and ambulatory 14 days after admission with normal motion of the cardiac wall. This is the first case of Kounis syndrome associated with takotsubo cardiomyopathy. The mechanism of the concurrent condition of this case is herein discussed.

Pontine infarction induced by injury of the perforating branch of the basilar artery after blunt head impact: case report.

A 77-year-old male pedestrian was hit by a car. On admission, he had disturbance of consciousness and left hemiplegia. Computed tomography (CT) indicated only left frontal subcutaneous hematoma and minor hemorrhage in the left frontal lobe, suggesting axonal injury. CT on hospital day 2 revealed a low density area in the right paramedian pons, but CT angiography showed no dissection or occlusion of the vertebrobasilar artery. The diagnosis was pontine infarction resulting from shearing force injury to the paramedian branch of the basilar artery. He was transferred to another hospital for rehabilitation without improvement of symptoms on hospital day 51. Paramedian pontine infarction tends to occur in patients with risk factors for arteriosclerosis, including hypertension, diabetes mellitus, hyperlipidemia, or smoking. The present elderly patient had hypertension and hyperlipidemia, so arteriosclerosis in the paramedian branch may have contributed to his susceptibility to such injury.

Sudden asphyxial cardiac arrest due to esophageal cancer.

A 65-year-old woman with a sore throat and cough suddenly collapsed. She regained spontaneous circulation following resuscitation, but hypoxic encephalopathy was identified. Her vocal cords and the results of chest radiography were normal and no obstructive mass was identified in the neck on computed tomography (CT), but she demonstrated signs of obstructive upper airway. Bronchoscopy revealed tracheal stenosis. Chest CT showed tracheal compression by an esophageal tumor. Investigation of the trachea and surrounding organs by bronchoscopy and CT is important even when a patient with suspected respiratory arrest displays normal findings on chest radiography.

Hyperammonemia is associated with generalized convulsion.

PURPOSE: The possibility that hyperammonemia may be associated with generalized convulsion (GC) was retrospectively investigated. METHODS: Subjects comprised 17 patients with GC who were transported to our department and underwent analysis of serum biochemistry, including ammonia, since October 2004. RESULTS: Causes of convulsion included intracranial lesions (n=8), endocrine diseases (n=2), epilepsy (n=2) and others (n=5). Ammonia levels in all cases exceeded the upper limit of normal range. Ammonia levels in 8 subjects were re-checked on hospital day 2, and all were lower than levels on hospital day 1 without any treatment for hyperammonemia. CONCLUSION: GC itself appears to be associated with hyperammonemia. Although hyperammonemia is also known to induce convulsion, biochemical analysis immediately after GC is not useful for diagnosing hyperammonemia-induced convulsion.

Early diagnosis of hypovolemic shock by sonographic measurement of inferior vena cava in trauma patients.

BACKGROUND: The diameter of the inferior vena cava in trauma patients may be useful for evaluating hypovolemia. METHODS: Between June 2003 and September 2003, 35 injured patients transferred to the authors' hospital were prospectively investigated. They were divided into two groups: a shock group (n = 10) and a control group (n = 25). The maximum anteroposterior diameter of the inferior vena cava was measured using a sonography at arrival and on hospital day 5. RESULTS: The average diameter of the inferior vena cava in the shock group was significantly smaller than in the control group. There was no significant change in the diameter of the inferior vena cava in the control group, but significant change was seen in the shock group between arrival and hospital day 5. CONCLUSION: The diameter of the inferior vena cava was found to correlate with hypovolemia in trauma patients.