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Recently, addiction to regular doses of hypnotics has become a problem. While many patients report a desire to reduce their dosage, many do not agree with their physicians’ suggestions for reduction. In this study, we created an online short video targeting patient motivation to reduce hypnotics usage and examined its efficacy and factors associated with the intention to reduce medication. We created a 10 min video that included “sleep education,” “guidance for reducing the use of hypnotics,” and “systematic motivation for reducing the use of hypnotics” and posted it on our website. For 1 year, we conducted a questionnaire survey to determine the effectiveness of the video and factors associated with the intention to reduce hypnotics use. Of 4548 viewers, 609 (13.4%) completed the questionnaire, 369 (67.9%) of whom used hypnotics. Most respondents were older adults. The intention to reduce medication use was significantly strengthened after watching the video in 37.7% of medication users (effect size 0.404). In the group that was not inclined toward medication reduction before viewing, 85.2% of patients had stronger intentions to reduce medication use after watching the video (effect size 0.818). “Memorable content about side effects” was extracted as a factor related to reinforcement of the intention to reduce medication use, suggesting that prescribing physicians’ descriptions of current insomnia treatment is inadequate in explaining side effects to patients. A short informational video can have beneficial effects on patients’ motivation for dose reduction or cessation of hypnotics.

Background Computed tomography (CT) is often performed to assess patients; however, little is known about how airway size measured by CT scan imaging might influence the occurrence of post-extubation upper airway obstruction. Methods This study aimed to evaluate the association between airway size measured by CT and the incidence of post-extubation upper airway obstruction symptoms for each sex. This single-center observational study was conducted at a tertiary emergency medical center/severe trauma center with a 12-bed intensive care unit. We enrolled consecutive adult patients (aged ≥ 20 years), who were intubated in the emergency room, between January 2016 and March 2019. Patients who underwent a CT scan of the glottic region within three hours before and after intubation were included in the analysis. For each sex, we first divided the patients into two groups: those who had post-extubation stridor, hoarseness, or both and those who had no such symptoms. Then, we compared the two groups using the Mann–Whitney U test and Fisher’s exact test. Univariate and multivariate logistic regression analyses were also performed. Results During the 39 months, 855 patients were enrolled in this study. A total of 217 patients underwent CT of the glottic region within three hours before and after intubation. Five patients had no records of symptoms after extubation. Thus, we analyzed data from 212 patients. This study included 144 males and 68 females. In female patients, the median [inter-quartile range] (average) of the transverse diameter of the glottis/endotracheal tube outer diameter (OD) ratio was smaller in patients with post-extubation upper airway obstruction symptoms than in patients without the symptoms (1.00 [1.00–1.00] (0.9572) vs. 1.00 [1.00–1.00] (1.00296), respectively; p = .013). Multivariate logistic regression analysis showed that the glottis/tube OD ratio Conclusions In female patients, no gap between the endotracheal tube and the vocal codes or the glottic transverse diameter being smaller than the endotracheal tube OD on CT scan was associated with post-extubation upper airway obstruction symptoms.

Background Coronavirus disease 2019 (COVID-19) pneumonitis associated with severe respiratory failure is associated with high mortality. The pathogenesis of COVID-19 is associated with microembolism or microvascular endothelial injuries. Here, we report that syndecan-1 (SDC-1), a component of the endothelial glycocalyx, may be a biomarker of severity classification for COVID-19 related to endothelial injury. Methods and analysis We analyzed the data of COVID-19 patients for 1 year from February 2020 at Yokohama City University Hospital and Yokohama City University Medical Center Hospital. We selected COVID-19 patients who required admission care, including intensive care, and analyzed the classification of severe and critical COVID-19 retrospectively, using various clinical data and laboratory data with SDC-1 by ELISA. Results We analyzed clinical and laboratory data with SDC-1 in five severe COVID-19 and ten critical COVID-19 patients. In the two groups, their backgrounds were almost the same. In laboratory data, the LDH, CHE, and CRP levels showed significant differences in each group (P = 0.032, P P = 0.007, respectively) with no significant differences in coagulation-related factors (platelet, PT-INR, d-dimer, ISTH score; P = 0.200, 0.277, 0.655, and 0.36, respectively). For the clinical data, the SOFA score was significantly different from admission day to day 14 of admission (p P = 0.009 and P Conclusions Temporal change of SDC-1 levels closely reflect the severity of COVID-19, therefore, SDC-1 may be a therapeutic target and a biomarker for the severity classification of Covid-19.

The prognosis of out-of-hospital cardiac arrest has improved in Japan due to the increasing availability of automated external defibrillators. However, priority should be placed on specificity to not perform unnecessary waveforms rather than sensitivity to perform defibrillation on necessary waveforms. This report describes a case in which the f-wave of bradycardic atrial fibrillation was erroneously analyzed and defibrillated. Health care workers should be aware that the f-wave of bradycardic atrial fibrillation may be erroneously assessed as fine ventricular fibrillation; they should change it to the manual mode and respond as necessary.

Introduction The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma. Case A 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15. Conclusion When we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.

Background: Some patients with severe coronavirus disease (COVID-19) who present with fibrosis on computed tomography (CT) require prolonged mechanical ventilation (PMV). Lung ultrasound (LUS), a rapid, bedside test, has been reported to have findings consistent with those of CT. Thus, this study aimed to assess whether serial LUS scores could predict PMV or successful extubation in severe COVID-19 patients.Methods: LUS was performed for 20 consecutive severe COVID-19 patients at three time points: admission (day 1), after 48 h (day 3), and seventh-day follow-up (day 7). We compared the LUS score with the results of chest X-rays and laboratory tests at three time points. Moreover, we assessed LUS score to determine the inter-rater reliability (IRR) of the results among examiners.Results: While there were no significant differences in mortality in each PMV and successful extubation groups, there were significant differences in LUS scores on day 3 and day 7; XP score on day 7; and P/F ratio on day 7 in the PMV group (pConclusions: The serial LUS score of severe COVID-19 patients could predicted PMV and successful extubation. To overcome IRR disagreement, the automatic ultrasound judgement, such as deep learning, would be needed.

Background Veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) is one of the ultimate treatments for acute respiratory failure. However, the effectiveness of ECMO in patients with novel coronavirus disease (COVID‐19) is unknown. Case Presentation A 72‐year‐old woman who was a passenger of a cruise ship tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) while in quarantine on board using throat swab. Three days after admission, her condition deteriorated, and she was subsequently intubated. On day 6, VV‐ECMO was introduced. Lopinavir/ritonavir was given; continuous renal replacement therapy was also introduced. On day 10, her chest radiography and lung compliance improved. She was weaned off ECMO on day 12. Conclusion Treatment of severe pneumonia in COVID‐19 by ECMO should recognize lung plasticity considering time to ECMO introduction and interstitial biomarkers. In Japan, centralization of ECMO patients has not been sufficient. Thus, we suggest nationwide centralization and further research to respond to the crisis caused by COVID‐19., ECMO is one of the treatment options in severe ARDS by SARS‐CoV‐2. It is important to recognize lung plasticity. Centralization of COVID‐19 ECMO patients may be effective in Japan.

Objective: Traumatic duodenal obstructions are rare, and most are caused by compression from intramural or retroperitoneal macroscopic hematomas. This report describes a very rare type of delayed traumatic duodenal obstruction without macroscopic intramural or extraluminal hematoma caused by traumatic fibrosis due to seromuscular and intramural injury and microscopic hemorrhage. Case presentation: A 31-year-old man was transferred to our center due to polytrauma with nausea and vomiting on day 53 after an accident. Gastrointestinal fiberscopy (GIF) on day 57 revealed an active stage small duodenal ulcer with patency of the pyloric ring. Although the patient underwent subdural drainage, the nausea and vomiting continued. A repeat GIF on day 91 revealed a duodenal ulcer with severe pyloric stenosis. GIF after nasogastric drainage on day 102 identified a severe pinhole stenosis. We performed surgery on day 106 and observed a constricted duodenal bulb due to a tumorous scar. We resected the stenotic section of the duodenal bulb including the pyloric ring. Conclusion: The histopathologic examination revealed constriction and fibrosis. Surgical options should be considered for patients with delayed duodenal obstruction without macroscopic hematoma around the duodenum after several months of hospitalization.

Background To improve acute trauma care workflow, the number of trauma centers equipped with a computed tomography (CT) machine in the trauma resuscitation room has increased. The effect of the presence of a CT machine in the trauma room on a patient’s outcome is still unclear. This study evaluated the association between a CT machine in the trauma room and a patient’s outcome. Methods Our study included all trauma patients admitted to a trauma center in Yokohama, Japan, between April 2014 and March 2016. We compared 140 patients treated using a conventional resuscitation room with 106 patients treated in new trauma rooms equipped with a CT machine. Results For the group treated in a trauma room with a CT machine, the Injury Severity Score (13.0 vs. 9.0; p = 0.002), CT scans of the head (78.3 vs. 66.4%; p = 0.046), CT scans of the body trunk (75.5 vs. 58.6%; p = 0.007), intubation in the emergency department (48.1 vs. 30.7%; p = 0.008), and multiple trauma patients (47.2 vs. 30.0%; p = 0.008) were significantly higher and Trauma and Injury Severity Score probability of survival (96.75 vs. 97.80; p = 0.009) was significantly lower than the group treated in a conventional resuscitation room. In multivariate analysis and propensity score matched analysis, being treated in a trauma room with a CT machine was an independent predictor for fewer hospital deaths (odds ratio 0.002; 95% CI 0.00–0.75; p = 0.04, and 0.07; 0.00–0.98, respectively). Conclusions Equipping a trauma room with a CT machine reduced the time in decision-making for treating a trauma patient and subsequently lowered the mortality of trauma patients.

Background The coronavirus disease 2019 (COVID-19) pandemic rapidly increases the use of mechanical ventilation (MV). Such cases further require extracorporeal membrane oxygenation (ECMO) and have a high mortality. Objective We aimed to identify prognostic biomarkers pathophysiologically reflecting future deterioration of COVID-19. Methods Clinical, laboratory, and outcome data were collected from 102 patients with moderate to severe COVID-19. Interleukin (IL)-6 level and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA copy number in plasma were assessed with ELISA kit and quantitative PCR. Results Twelve patients died or required ECMO owing to acute respiratory distress syndrome despite the use of MV. Among various variables, a ratio of oxygen saturation to fraction of inspired oxygen (SpO2/FiO2), IL-6, and SARS-CoV-2 RNA on admission before intubation were strongly predictive of fatal outcomes after the MV use. Moreover, among these variables, combining SpO2/FiO2, IL-6, and SARS-CoV-2 RNA showed the highest accuracy (area under the curve: 0.934). In patients with low SpO2/FiO2 (< 261), fatal event-rate after the MV use at the 30-day was significantly higher in patients with high IL-6 (> 49 pg/mL) and SARS-CoV-2 RNAaemia (> 1.5 copies/μL) compared to those with high IL-6 or RNAaemia or without high IL-6 and RNAaemia (88% vs. 22% or 8%, log-rank test P = 0.0097 or P < 0.0001, respectively). Conclusions Combining SpO2/FiO2 with high IL-6 and SARS-CoV-2 RNAaemia which reflect hyperinflammation and viral overload allows accurately and before intubation identifying COVID-19 patients at high risk for ECMO use or in-hospital death despite the use of MV.

This study was aimed to clarify the changes in Non-REM sleep by menstrual cycle using polysomnography with the Cyclic Alternating Pattern (CAP) analysis. The subjects were twelve healthy women having regular menstrual cycles (mean age: 29.5 ± 4.4 years old). As the results of our study, the conventional sleep parameters did not significantly differ between different phases of the sexual cycle. However, the CAP rate, which represents instability of sleep, was significantly higher in Luteal phase (Lp) than in Follicular phase (Fp) (Lp: 38.7 ± 2.81 %, Fp: 28.6 ± 1.8). It was suggested that the worsening of sleep instability might cause the lowered sleep quality in Lp.

Our unique rapid response system (RRS) includes a systematically organized structure by rapid response teams (RRT) and a nonorganized, nonsystematic structure for gathering hospital staffs in the scene. We examined the records of 54 patients described in this RRS. Our RRS is as follows; a medical/non-medical hospital staff who finds a victim, asks other staffs to activate the RRS by using inhospital whole paging system; predefined staffs bring predefined equipments; a standard educational course and e-learning system and a simple recording form. The mean interval between the event and the arrival of staff at the scene was 1.81 minutes. Hospital death rate per total discharged patients tended to decrease after RRS. Our unique RRS work well. The death rate among discharged patients decreased after this system was implemented.

The authors evaluated the effects of brief group cognitive behavioral therapy for insomnia (G-CBT-I) in outpatients with psychophysiological insomnia (PPI). This brief G-CBT-I was designed to yield results in a shorter period of time, because its strategy was intended to lower the dropout rate and enhance the cost performance. And also, it was intended to be easy to make use of CBT-I for both therapists and patients. This process consists of four components and only two sessions weekly, and a total therapy time is approximately 3 h. Thirty-three participants (including 17 women) with PPI received G-CBT-I therapy. The short-term outcome (4 weeks after G-CBT-I) was measured using sleep logs, actigraphy, the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J), and the Japanese version of the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-J). The long-term outcome was evaluated by checking medical records at 6 months after G-CBT-I. At 4 weeks after G-CBT-I, subjective sleep onset latency decreased by 32.1%, and objective sleep efficiency increased to approximately 90%. The dissociation between subjective and objective evaluations of sleep decreased. The total score of the PSQI-J and the scores on the DBAS-J (“consequences of insomnia”, “control and predictability of sleep”, and “sleep-promoting practice”) were decreased. At the long-term follow-up, the amount of hypnotics needed by each participant decreased by 0.6 mg (1 being equivalent to 1 mg of flunitrazepam) (33% reduction). These findings suggested that patients with PPI could derive significant benefit from brief G-CBT-I therapy.

Background: The aim of this study is to clarify the circumstances including the locations where critical events resulting in out-of-hospital cardiopulmonary arrest (OHCPA) occur. Materials and Methods: Subjects of this population-based observational case series study were the clinical records of patients with nontraumatic and nonneck-hanging OHCPA. Results: Of all 1546 cases, 10.3% occurred in a public place (shop, restaurant, workplace, stations, public house, sports venue, and bus), 8.3% on the street, 73.4% in a private location (victim's home, the homes of the victims' relatives or friends or cheap bedrooms, where poor homeless people live), and 4.1% in residential institutions. In OHCPA occurring in private locations, the frequency of asystole was higher and the outcome was poorer than in other locations. A total of 181 OHCPA cases (11.7%) took place in the lavatory and 166 (10.7%) in the bathroom; of these, only 7 (3.9% of OHCPA in the lavatory) and none in the bath room achieved good outcomes. The frequencies of shockable initial rhythm occurring in the lavatory and in bath room were 3.7% and 1.1% (lower than in other locations, P = 0.011 and 0.002), and cardiac etiology in OHCPA occurring in these locations were 46.7% and 78.4% (the latter higher than in other locations, P Conclusions: An unignorable population suffered from OHCPA in private locations, particularly in the lavatory and bathroom; their initial rhythm was usually asystole and their outcomes were poor, despite the high frequency of cardiac etiology in the bathroom. We should try to treat OHCPA victims and to prevent occurrence of OHCPA in these risky spaces by considering their specific conditions.

The purpose of this study was to compare the efficacy of individual and group cognitive behavioral therapy for insomnia (CBT-I) in outpatients with primary insomnia diagnosed by DSM-IV-TR. The participants were 20 individually treated (I-CBT-I) and 25 treated in a group therapy format (three to five patients per group) (G-CBT-I), which showed no significant difference regarding demographic variables between groups. The same components of CBT-I stimulus control therapy, sleep restriction therapy, cognitive therapy, and sleep hygiene education were applied on both groups. The short-term outcome (4 weeks after treatment) was measured by sleep logs, actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), and was compared between I-CBT-I and G-CBT-I. The results indicated that CBT-I was effective in improving subjective and objective sleep parameters and subjective sleep evaluations for both individual and group treatment. However, I-CBT-I resulted in significantly better improvements over G-CBT-I, in (i) objective and subjective sleep onset latency time, (ii) objective sleep efficacy and moving time during sleeping, (iii) overall sleep quality and duration of actual sleep time in PSQI, (iv) consequences of insomnia, control and predictability of sleep, sleep requirement expectation, and sleep-promoting practices in DBAS. The present study suggested the superiority of I-CBT-I over G-CBT-I in clinical settings, and further evaluations are necessary.

Background: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). Materials and Methods: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. Results: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. Conclusion: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.

Background: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. Materials and Methods: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients’ medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. Results: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. Conclusion: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

The purpose of this study was to assess factors associated with subjective sleep evaluation, chiefly excessive daytime sleepiness (EDS) in obstructive sleep apnea syndrome (OSAS) adult outpatients under continuous positive airway pressure (CPAP) treatment. One thousand and forty-eight OSAS outpatients (mean age: 51.4% male: 90.5%) who were treated by CPAP were consecutively collected. Age, sex, CPAP compliance (CPAP usage as their device of nights with application-time of at least 4 hours per night objectively; %usage ≥ 4 h/d), and Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J) of the patients showing EDS (Japanese version of the Epworth Sleepiness Scale; JESS ≥ 11) were compared cross-sectionally with those of the patients who did not show EDS (JESS < 11). Nineteen point two % of all patients showed EDS subjectively. Two hundred one patients were classified to an EDS(+) group and an 847 patients were classified to EDS(–) group. Age and global PSQI-J scores were significantly different between the two groups. Logistic regression showed that EDS was significantly associated with global PSQI-J scores, but not with age. Among PSQI-J components, overall sleep quality, duration of sleep, sleep disturbance, and day dysfunction due to sleepiness were significantly higher in the EDS(+) group. Especially, 19.4% of patient in the EDS(+) group reported actual sleep time during the past month to be less than 5 hours/day. Although functional relationship should be further evaluated, insufficient sleep is the main factor associated with EDS in the OSAS patients under CPAP treatment.

High-echoic objects in the hepatic vessels of patients with cardiopulmonary arrest (CPA) are frequently detected by ultrasonography.To demonstrate this phenomenon and clarify its clinical characteristics.In a tertiary care academic medical centre, 203 CPA patients were evaluated by ultrasonography. CT determined the origin and location of high-echoic objects detected in the liver. The frequency and characteristics of this phenomenon were investigated. The background, laboratory data and survival rate were compared between patients with and without high-echoic objects.High-echoic objects were seen in 73 (36.0%) patients and could clearly be detected in the hepatic veins of 41 (56.2%) patients. CT confirmed that these were gas in 27 of 53 patients, and were clearly visible in the hepatic veins in 12 (44.4%) patients. Hepatic portal venous gas was not identified. Compared to patients without high-echoic objects, witnessed arrest (p0.001), bystander cardiopulmonary resuscitation (p=0.005), ventricular fibrillation or pulseless electrical activity (p=0.012) and return of spontaneous circulation (p=0.018) were significantly less frequent in patients with high-echoic objects. These patients had a lower incidence of survival to discharge (1.4% vs 7.7%, p=0.100). Multivariate analysis showed that absence of high-echoic objects was a marginally significant factor in association with return of spontaneous circulation (p=0.052).High-echoic objects were often observed on ultrasonography in CPA patients; these objects were considered hepatic venous gas. The presence of high-echoic objects may be a poor prognostic sign in patients with CPA.

The average of sleep time in Japanese is decreasing year by year. According to data of NHK's survey, it has been lowered by one hour since 1960. The reasons are different between generations. In adolescence, the increased frequency of using internet and convenience store may cause the shortage of sleep and the deterioration of circadian rhythms. In adulthood, the working environment, such as increased number of shift-workers and excessive job time, is getting worse, and it could shorten the sleep time and exacerbate sleep quality. In old age, the frequency of taking medicine becomes higher in connection with aging. We need to be careful about the interactions between hypnotics and taking drugs prescribed to treat complications.

Background Therapeutic hypothermia (TH) is one of the key treatments after cardiac arrest (CA). Selection of post-CA patients for TH remains problematic, as there are no clinically validated tools to determine who might benefit from the therapy. Objective The aim of this study was to investigate retrospectively whether laboratory findings or other patient data obtained during the early phase of hospital admission could be correlated with neurological outcome after TH in comatose survivors of CA. Methods Medical charts of witnessed CA patients admitted between June 2003 and July 2009 who were treated with TH were reviewed retrospectively. The subjects were grouped based on their cerebral performance category (CPC) 6 months after CA, as either good recovery (GR) for CPC 1–2 or non-good recovery (non-GR) for CPC 3–5. The following well-known determinants of outcome obtained during the early phase of hospital admission were evaluated: age, gender, body mass index, cardiac origin, presence of ventricular fibrillation (VF), time from collapse to cardiopulmonary resuscitation, time from collapse to return of spontaneous circulation, body temperature, arterial blood gases, and blood test results. Results We analyzed a total of 50 (25 GR and 25 non-GR) patients. Multivariate logistic analysis showed that initial heart rhythm and pH levels were significantly higher in the GR group than in the non-GR group (ventricular tachycardia/VF rate: p = 0.055, 95% confidence interval [CI] 0.768–84.272, odds ratio [OR] 8.047; pH: 7.155 ± 0.139 vs. 6.895 ± 0.100, respectively, p Conclusion These results imply that in addition to initial heart rhythm, pH level may be a good candidate for neurological outcome predictor even though previous research has found no correlation between initial pH value and neurological outcome.

Forty eight year-old woman with untreated liver cirrhosis was transferred to our critical care and emergency center because of airway crisis due to retropharyngo-esophageal hematoma after slight chest contusion. We performed emergency tracheal intubation beyond stenotic part of the trachea. The hematoma did not diminished in a few days. Although we considered tracheostomy, we hesitated to perform conventional median tracheostomy because of the risk of complication of infection of the hematoma which might require drainage or removal resulting in contamination between tracheostomy site and cervical wound. We performed paramedian tracheostomy by antero-lateral skin incision to avoid these risks. Fortunately, the patient did not require drainage of the retropharyngo-esophageal hematoma. Paramedian tracheostomy should be taken into account for patients with presumably contaminated cervical wound.

Tracheostomy is hardly performed in patients with cervical infection close to the site of the tracheostomy. This study aimed to present and clarify the usefulness and safety of open tracheostomy performed by the paramedian approach technique. The procedure is as follows. A 2.5-cm paramedian incision is made for the tracheostomy on the opposite side of infectious focus; the anterior neck muscles are dissected and split; the trachea is fenestrated by a reverse U-shaped incision; and the fenestral flap of the trachea is fixed to the skin. We used this technique in five patients. There were no complications such as bleeding, desaturation, and displacement of the tube; and there were no postoperative complications such as severe contamination or infection of the tracheostomy site from the nearby cervical wound, difficulty in securing the tracheostomy tube and connecting device to the ventilator, difficulties in daily management and care, or dislocation of the tracheostomy tube. All wounds resulting from the tracheostomy were kept separate from and not contaminated by the nearby dirty wounds. Open tracheostomy by the paramedian approach technique is useful and safe for patients with severe cervical infection requiring open drainage and long ventilatory management.

There are few strategies for treating patients who have suffered cardiopulmonary arrest due to blunt trauma (BT-CPA). The aim of this population-based case series observational study was to clarify the outcome of BT-CPA patients treated with a standardized strategy that included an emergency department thoracotomy (EDT) under an emergency medical service (EMS) system with a rapid transportation system. The 477 BT-CPA registry data were augmented by a review of the detailed medical records in our emergency department (ED) and action reports in the prehospital EMS records. Of those, 76% were witnessed and 20% were CPA after leaving the scene. In all, 18% of the patients went to the intensive care unit (ICU), the transcatheter arterial embolization (TAE) room, or the operating room (OR). Only 3% survived to be discharged. Among the 363 witnessed patients—11 of whom had ventricular fibrillation (VF) as the initial rhythm, 134 exhibiting pulseless electrical activity (PEA), and 221 with asystole—13, 1, and 3%, respectively, survived to discharge. The most common initial rhythm just after collapse was not VF but PEA, and asystole increased over the 7 min after collapse. There were no differences in the interval between arrival at the hospital and the return of spontaneous circulation between the patients that survived to discharge and deceased patients in the ED, OR, TAE room, or ICU. The longest interval was 17 min. In BT-CPA patients, a 20-min resuscitation effort and termination of the effort are thought to be relevant. The initial rhythm is not a prognostic indicator. We believe that the decision on whether to undertake aggressive resuscitation efforts should be made on a case-by-case basis.

Some patients with perianal infection fall into a critical condition with severe sepsis and septic shock (lethal perianal infection). The objective of this study is to clarify the clinicopathological characteristics of, and treatment strategies for, lethal perianal infection. The clinical records of 7 patients with lethal perianal infection were examined. For two rapidly dying cases (within 3 days), we performed resection of the rectum or local anal drainage as a primary management of damage control. These patients were transferred to our center because of septic shock and multiple organ dysfunction syndrome (MODS) and had received insufficient fluid resuscitation in the previous hospital. Another nonsurviving case who died on the 16th day was transferred without MODS and underwent perianal drainage but could not recover from shock, even after repeated surgical procedures were performed. To prevent a perianal infection from becoming lethal, it should be managed as early as possible with sufficient fluid resuscitation with adequate drainage.

We experienced a traumatic victim with thoracic and abdominal injury with hemorrhagic shock, who was successfully treated with damage control. Thoracic drainage revealed more than 300 ml/hour of continuous hemorrhage in the left thoracic cavity with 60-80 mmHg of non-responding hypotention. Although we performed emergency partial resection of the injured lung, intraabdominal packing and transcatheter arterial embolization, intrathoracic hemorrhage and hemorrhagic shock was not controlled. We decided re-thoracotomy and performed peri-pulmonary packing around the injured lung, by which we successfully controlled temporary intrathoracic hemorrhage and definitive left lower lobectomy. Peri-pulmonary packing was effective for intrathoracic hemostasis without lethal ventilatory and circulatory complication in this case.

The objective of this study is to clarify the pathological condition and treatment strategy of lethal obstructive colitis (LOC), which is defined as obstructive colitis with severe shock or septic shock.We examined 5 patients with LOC (colorectal cancer or suspected in 2, fecal impaction in 2, and volvulus in 1) and evaluated their pathophysiology and management strategy from their medical records.Emergency operations were performed within 150 minutes from arrival in all cases. Three were saved by repeat operations and 2 died. The systolic pressure of both survived and deceased patients were under 62 or palpable only on the common carotid artery, and there was no difference between survived and deceased patients. The mean pulse rate of the deceased patients was 76.5 while survived 117.7. Two deceased patients presented unconsciousness or conscious disorder while survived patients showed clear consciousness. The 2 deceased patients fell into VT just after arrival or during the operation.In managing colonic obstruction, we should be aware of this potentially lethal disease and surgical treatment should be performed as soon as possible before the patients fall into LOC. Early diagnosis and early aggressive surgery is essential for managing LOC.