【背景】 Kounis症候群はアレルギー反応で急性冠症候群を来す稀な疾患である。その誘因として昆虫刺傷や薬剤がほとんどであり，哺乳類咬傷での報告はない。今回，ハムスター咬傷を契機に発症した症例を経験し，本症例の誘因，診断に示唆を与えるため報告する。 【症例】 健康な30歳代の男性が卒倒して意識障害の情報でドクターカー出動となり，患者接触前にハムスター咬傷後に卒倒したことが判明した。接触時は血圧147/90mmHg，全身発汗があり，意識レベルがE1V1M1，酸素飽和度60%台であった。皮疹はなく換気抵抗もなかったためアナフィラキシーおよびくも膜下出血の可能性を考慮して病院前で気管挿管・アドレナリン投与は行わず，バックバルブマスク換気で自院へ搬送した。病着後に頭蓋内出血を否定し，アドレナリン投与で全身発汗・意識障害は改善した。しかし血圧低値は遷延し，グルカゴン投与後に気管挿管した。胸痛症状や心臓超音波検査で異常はなかったが，心電図でST上昇を認め，経過からKounis症候群を発症したと考えられた。若年者で既往歴もなかったため血管造影検査は行わずICU入室となった。入室翌日にはST変化は改善し，胸痛症状もなく抜管して3日目に退院した。 【結語】 哺乳類咬傷でもKounis症候群を発症しうることを啓発するとともに，重症アナフィラキシー症例ではKounis症候群の合併を考慮して対応すべきである。
Objectives : In Japan, evidence of lower limb ischemia (LLI) associated with using a percutaneous microaxial ventricular assist device (Impella, Abiomed, Danvers, MA) remains limited. This study aimed to investigate the incidence, risk factors, and treatment interventions for LLI in patients with Impella. Methods : This study included 47 patients who underwent Impella insertion via the femoral artery at Hiroshima University Hospital between January 2019 and December 2024. We collected patient characteristics and analyzed the treatment interventions and ischemic outcomes. Groups with and without LLI were compared using univariate analysis. Results : Thirty–six patients (77%) were men, with a median age of 62 years. The most common cause was acute coronary syndrome (20 patients, 43%). Impella–CP was selected in 42 cases (89%), and V–A ECMO was simultaneously applied in 20 cases (42%). LLI was observed in six patients (13%). No significant differences were found in patient characteristics between both groups. Regarding treatment interventions, distal perfusion was performed in four patients, Impella removal in one patient, and change in insertion site in one patient. LLI improved in all patients. Conclusion : The incidence of LLI is not low in patients undergoing Impella implantation. Early recognition and appropriate interventions, including distal perfusion, are important to improve patient outcomes.
In Japan, strategies for emergency surgery under chemical, biological, radiological, nuclear, and explosive (CBRNE) conditions remain undeveloped. In urgent situations, treatment may commence with inadequate decontamination, thereby increasing the risk of exposure of healthcare workers. It is crucial to implement appropriate safety measures to prevent secondary injuries in medical staff and patients. We present a case of a male engaged in industrial waste management who fell from a height of two meters into a wastewater tank containing residual hexavalent chromium. After the fall, a rope supporting a metal object was detached, and his abdomen was struck. His buttocks and lower limbs were submerged in the wastewater. On–site decontamination procedures were performed before the patient was transported; however, his hemodynamic status continued to deteriorate. He arrived at the hospital in shock and was diagnosed with an intra–abdominal hemorrhage. After additional decontamination, emergency surgery was performed. Contaminated skin on his scrotum developed chemically induced ulcerative necrosis that required debridement. Pre–operative identification of the causative substance allowed for sufficient decontamination and enabled safe surgery. It would also be desirable to establish a trauma care system in Japan that incorporates standard precautions for management of CBRNE conditions.
A table salt overdose can cause fatal hypernatremia. In the treatment of common hypernatremia, slow correction is recommended because rapid correction leads to central nervous system complications. However, there are currently no established treatments for table salt poisoning. A female in her 40s with vomiting was transferred to our emergency room one hour after ingesting 50 g of table salt. On arrival at our hospital, the patient’s consciousness improved. Laboratory testing revealed a serum sodium level of 157 mEq/L. Fluid therapy was initiated with a 5% dextrose solution. However, five hours later the serum sodium level had increased to 173 mEq/L. We determined that it would be difficult to compensate with infusion therapy alone; therefore, continuous hemodiafiltration was initiated. After four hours of hemodiafiltration, the serum sodium level decreased to 156 mEq/L. The patient’s consciousness remained clear. The patient was discharged on the fifth day without any complications. Although the correction rate was more rapid than recommended, the patient was treated without complications. In acute hypernatremia due to table salt poisoning, a rapid correction of 2 mEq/L/hr or greater may be effective.
The case is a 61–year–old male. He had multiple traumatic injuries due to motorcycle accident, which required ventilator management, tracheotomy, and ventriculoperitoneal shunt implantation. On the 110th day after the injury, he contracted a COVID–19 and was treated with Remdecivir. Twelve days later, he manifested significant clinical bleeding, including an intramuscular hematoma in the left thigh and prolonged APTT, leading to a diagnosis of acquired hemophilia A (AHA) confirmed by cross–mixing test results. He was treated with transarterial catheter embolization, surgical hemostasis, active eptacog alfa, and emicizumab as hemostatic therapy, and steroid therapy as immunosuppressive therapy, and he went into remission. The course of the case suggested that AHA was induced by COVID–19 infection, but similar conditions are very rare. In previous reports, there is no correlation between the severity of COVID–19 infection and the risk of developing AHA, and in many cases, the initial symptom is subcutaneous or intramuscular bleeding without trauma or other triggers. Since AHA has a relatively good prognosis despite the need for specialized treatment such as bypass therapy and immunosuppression, early diagnosis and appropriate initiation of treatment are important when clinical bleeding tendency is observed, even in mild cases.
A case of severe coronavirus disease–2019 (COVID–19) complicated by hypothyroidism during treatment is reported where differentiating myxedema coma and Low triiodothyronine (T3) syndrome associated with sepsis was challenging. A 73–year–old male with deteriorating oxygenation folLowing COVID–19 infection (PaO 2 62.1 mmHg, 5L oxygen supplied via mask) was admitted. On day 3, lung oxygenation capacity decreased (PaO 2 /F i O 2 of 88), necessitating mechanical ventilation. The patient developed hypothermia (rectal temperature of 34.8℃) on day 25 and impaired consciousness (Glasgow coma scale E2VTM1) on day 27. Thyroid–stimulating hormone (TSH), free thyroxine (FT4), and free T3 levels were 1.86 (0.61–4.23) μIU/mL, 49 (90–170) ng/mL, and 0.94 (2.3–4.0) pg/mL, respectively, indicating thyroid dysfunction. Based on the hypothermia, impaired consciousness, and thyroid dysfunction, the patient met the diagnostic criteria for myxedema coma, and thyroid hormone replacement therapy was initiated. Despite improvement in FT4 levels and temperature, the patient’s condition deteriorated due to progressive bacterial and fungal sepsis on day 35, resulting in death. In severe infections, myxedema coma and Low T3 syndrome present overlapping clinical manifestations. When clear symptoms meet diagnostic criteria for myxedema coma, thyroid hormone replacement should be considered after weighing risks.
Background : Critical massive hemorrhage is a significant issue in emergency medicine, and early transfusion therapy is crucial for saving lives. This study aimed to elucidate the handling of blood products for transfusion in pre–hospital emergency care and characterize the patients eligible for such administration. Methods : We surveyed the status of blood products taken out and transfused, patient background variables, and outcomes in cases of physician–staffed helicopter and ambulance dispatches at Tokai University Hospital from April, 2011 to March, 2022. Blood products for transfusion were transported in simple cooling boxes equipped with a thermometer, temperature analyzer, and temperature stabilizer. Results : Of the 2,621 dispatches, blood products for transfusion were transported in 247 cases and administered in 98 cases (transfused group). The transfused group tended to have lower systolic blood pressures and higher heart rates than the non–transfused (n=149) group. Among the transfused group, 67.3% had exogenous diseases (trauma) and 32.7% had endogenous diseases (mainly gastrointestinal bleeding). Conclusion : Due to the lack of a clear protocol for the pre–hospital administration of blood products for transfusion, on–site physicians must use their discretion. The transfusion of blood products may save lives in traumatic and non–traumatic cases, underscoring the need to establish appropriate transfusion protocols.
Uvular angioedema is a rare but potentially life–threatening condition that can cause upper airway obstruction. Inhalation of cocaine and cannabis have been identified as triggers worldwide. This case report describes uvular angioedema in a 15–year–old male; the condition was likely induced by inhalation of cigarette smoke. The patient presented at the emergency department with pharyngeal pain and dysphonia. Physical examination revealed significant uvular edema. Contrast–enhanced computed tomography revealed a swollen uvula measuring 12 × 14mm, confirming uvular angioedema. The patient was treated with antihistamines, corticosteroids, and antibiotics, which led to temporary improvement in the symptoms and swelling. However, his condition deteriorated with decreased oxygen saturation and administration of intramuscular epinephrine was unsuccessful. Due to worsening upper airway obstruction, awake nasotracheal intubation was performed, followed by mechanical ventilation for respiratory support. On Day 3, the swelling resolved, allowing successful extubation. Upon further history taking, the patient reported forceful cigarette inhalation prior to the onset of symptoms, accompanied by a burning sensation in his throat. This suggests that a thermal or allergic reaction to chemicals in the cigarette smoke may have triggered the angioedema. This case highlights the importance of recognizing uvular angioedema as a potential cause of airway obstruction.
A man in his 80s arrived at our emergency department with impaired consciousness and traumatic injuries to the trunk and lower limbs following a traffic accident. The initial evaluation revealed no airway, breathing, or circulatory compromise, but his Glasgow coma scale was E2V3M5. CT showed traumatic subarachnoid hemorrhage, left pulmonary contusion, multiple rib and pelvic fractures, and contrast retention in the proximal ileocolic artery with portal vein visualization, indicating mesenteric injury with arteriovenous fistula. No free intra–abdominal bleeding, bowel edema, or ischemia was observed. Management initially focused on other life–threatening injuries. Follow–up CT on days 2 and 7 showed persistent fistula; thus, elective ileocecal resection was performed on day 11, after his general condition stabilized. Postoperative recovery was uneventful, and he was transferred on day 78. Superior mesenteric arteriovenous fistulas may lead to complications such as portal hypertension. Elective surgery after improvement of the general condition may be an effective strategy.
A 50–year–old woman with type 2 diabetes mellitus treated by sodium–glucose co–transporter 2 (SGLT–2) inhibitors, underwent myomectomy for excessive menstruation. On postoperative day 4, she developed a persistent fever and was diagnosed with a pelvic abscess. Despite antibiotic therapy and transvaginal drainage, her condition deteriorated, necessitating emergency abdominal drainage on day 9. Following general anesthesia, she exhibited hypotension, tachycardia, hyperthermia, and prolonged metabolic acidosis, transfer to intensive care unit (ICU) admission for septic shock management. In the ICU, she received continuous noradrenaline and fluid resuscitation. Further investigation suggested euglycemic diabetic ketoacidosis (EDKA), potentially exacerbated by subclinical hyperthyroidism. After initiating continuous intravenous insulin with glucose, her condition rapidly improved. We believe the EDKA was primarily triggered by SGLT–2 inhibitor use, surgical stress, and sepsis, with subclinical hyperthyroidism possibly intensifying the metabolic disturbance. This case underscores the importance of recognizing the risk of EDKA in surgical patients using SGLT–2 inhibitors. Proactive monitoring and early intervention may prevent critical outcomes.
Background : While responder willingness is crucial for Chemical [C], Biological [B], Radiological/Nuclear [R/N], and Explosive [E] (CBRNE) incidents, Disaster Medical Assistance Team (DMAT) members show low response willingness, and their thought processes remain unclear. This study aimed to elucidate their decision–making processes. Methods : An anonymous 20–question survey was conducted among DMAT members in Fukushima and Nagasaki Prefectures, with 178 respondents analyzed. Participants rated their response willingness for six disaster types (natural disasters, human–made disasters, C, B, R/N, E) on a scale of 0–100%: 100% representing “strongly agree” and 0% representing “strongly disagree.” The primary outcome was response willingness for each disaster type. Factor analysis was performed for other questions by disaster type, and extracted latent factors were named based on related question content. Results : For natural disasters, five latent factors were identified: interest, educational environment, occupational norm, education/training, and private situation. Human–made disasters comprised four factors: interest, educational environment, occupational norm, and private situation. All CBRNE disasters consisted of only two factors: interest and educational environment. Conclusion : The thought processes for CBRNE disasters were relatively simplified with fewer latent factors. There is a need for educational opportunities to help DMAT members develop more complex decision–making processes for CBRNE disasters.
Community–acquired Pseudomonas aeruginosa pneumonia is rare in healthy individuals without any underlying diseases. The patient was a woman in her 50s with hypertension but no history of smoking. After a trip to a hot spring, she developed a fever and right chest pain. On admission, her SpO 2 level was 96% (room air). She was diagnosed with bacterial pneumonia and treated with ceftriaxone and levofloxacin. Her respiratory condition worsened, and she was intubated 14 hours after admission. Subsequently, she developed septic shock. On the third day of hospitalization, coagulopathy appeared, with a prolonged PT–INR of 6.15 and a decrease in platelet count to 30,000/µL. During her hospital stay, fresh frozen plasma (18 units) and concentrated platelets (60 units) were administered. On the fourteenth day, she was weaned off the ventilator. She was discharged on the 66th day. A later genetic analysis of the Pseudomonas aeruginosa strain revealed that it possessed exoenzyme S, T, and Y. Community–acquired Pseuodomonas aeruginosa pneumonia may possess exoenzymes, which can become severe with complications such as septic shock and coagulopathy. In the future, genetic testing will hopefully be applied in clinical practice to predict disease severity.
Patients on ECMO may develop neurological complications, and it is reportedly not rare for them to become brain–dead. We present an extremely rare case in Japan in which a patient on ECMO was legally declared brain–dead and became an organ donor. A female patient in her 30s with dyspnea was brought to the emergency department in out–of–hospital cardiac arrest. She was resuscitated using ECPR but was subsequently determined to be brain–dead. Legal brain death was confirmed while the patient was on VA–ECMO. During the apnea test, the ECMO oxygen sweep gas flow rate was initially set at 0.35 L/min and then reduced to 0.275 L/min, leading to a PaCO 2 level exceeding 60 mmHg in both the patient’s body and the ECMO circuit. Throughout the apnea test, PaO 2 remained stable, and the patient’s hemodynamics were maintained. The patient was legally declared brain–dead on the sixth day of illness, and organ donation was performed on the eighth day of illness. It is hoped that guidelines based on international standards will be developed in Japan and that organ donation in patients on ECMO will become standard practice as a transplantation option.
A 74–year–old man with consciousness disturbance was referred to our emergency center. He had atrial fibrillation and was taking 60 mg of edoxaban, which is a direct oral factor Xa inhibitor. Head computed tomography (CT) detected an intracranial hemorrhage (ICH) with a black hole sign (BHS), and CT angiography revealed a spot sign (SS). An intravenous injection of 400 mg at a target rate of 30 mg/min followed by intravenous infusion of 4 mg/min of andexnet alfa (AA) for 2 h was administered. Head CT revealed any hematoma expansion (HE) after 2–h, and effective hemostasis was achieved. He was discharged for rehabilitation with a modified Rankin Scale score of 4. Appearance of specific manifestations on CT, such as BHS or SS, was closely associated with an increased risk of HE and poor outcomes. Moreover, although AA reduces anti–factor Xa activity for up to 2 h after bolus administration, its role in ICH expecting HE remains unknown. The possibility that ICH stopped due to AA administration as well as the elapsed time was a concern in this case. Considering the specific mechanism of action, AA may be useful for improving hemostatic performance in patients with ICH expecting HE.
Abdominal Compartment Syndrome (ACS) is a life–threatening condition characterized by an elevated intra–abdominal pressure (IAP) of > 20 mmHg that causes organ dysfunction and requiring urgent treatment. Herein, we describe three cases of Linea Alba Fasciotomy (LAF) performed at our institution as a minimally invasive alternative to decompressive laparotomy in patients with ACS, achieving favorable outcomes. Case 1: A 42–year–old woman with primary ACS secondary to severe acute pancreatitis had an IAP of 52 mmHg. LAF was performed that reduced IAP to 21mmHg. Case 2: A 27–year–old man with secondary ACS due to diabetic ketoacidosis had an IAP of 49 mmHg. After LAF, IAP decreased to 20 mmHg. Case 3: A 49–year–old woman with primary ACS due to retroperitoneal hematoma caused by minor trauma had an IAP of 28 mmHg. After transcatheter arterial embolization and LAF, IAP decreased to 8 mmHg. LAF, performed by incising the linea Alba without opening the peritoneum, can effectively reduce IAP. It is a feasible procedure to perform in the ICU, simplifying postoperative management. In our patients, LAF reduced IAP by 20–30 mmHg. Therefore, we propose LAF as a minimally invasive first–line surgical option for ACS that reduces the complications associated with open laparotomy.
Most cases of necrotizing soft tissue infection (NSTI) are necrotizing fasciitis that is characterized by infection of the fascia, skin, and subcutaneous tissue. In rare cases, the infection is found in the muscles, and the causative pathogen is commonly group A beta–hemolytic streptococcus. We encountered a case of necrotizing fasciitis in a 54–year–old man caused by Aeromonas hydrophila . The patient was admitted to our hospital with fever and pain in the left lower leg. No blisters or redness were observed on the surface, and compartment syndrome was observed in the left lower leg. Myofascial incision surgery revealed nothing in the subcutaneous tissue or fascia suggesting infection or necrosis; however, the muscles exhibited a reddish–black color. Although empirical antimicrobial treatment was administered, the patient's condition deteriorated and he underwent lower leg amputation. However, infection control was not achieved and the patient died on the third hospitalization day. The cultured specimen revealed drug–resistant A. hydrophlia . NSTI without typical necrotizing myositis findings in the fascia may be accompanied by compartment syndrome, and early diagnosis is useful. This case illustrates that appropriate antimicrobial drug selection considering drug resistance is necessary, as Aeromonas spp . may be the causative bacteria and lead to serious outcomes.
Most U–shaped sacral fractures in young people are caused by high–energy trauma and are rarely associated with spasms. We present a case of an atraumatic U–shaped sacral fracture caused by a seizure in a young patient with epilepsy who was receiving long–term anticonvulsant therapy. A male in his 30s presented to the emergency department with severe lower back pain after a generalized tonic–clonic seizure. There were no episodes of trauma, such as falls, reported before or after the seizures. The symptoms were lower back pain and mild paresthesia in both lower extremities at admission. A computed tomography (CT) scan confirmed a U–shaped sacral fracture. The cauda equina nerve symptoms associated with the fractures were mild. Therefore, conservative treatment was selected. Diagnosing sacral fractures is challenging using radiography alone, often requiring a CT scan, as was the case here. It is important to examine patients complaining of lower back pain with the possibility of atraumatic fractures because cauda equina syndrome has a significant impact on a patient’s life.
Background : Early intervention is essential for improving the prognosis of patients with acute coronary syndrome (ACS). Reducing prehospital time is as essential as minimizing delays after hospital arrival. Paramedics play a key role in this effort, and proficiency in electrocardiogram (ECG) interpretation is vital for managing patients with chest pain. Despite its importance, few studies have focused on ECG training programs specifically tailored for paramedics. This study aimed to evaluate the effectiveness of a novel ECG training course. Methods : Fifty–eight paramedics from a fire department in Nagasaki Prefecture participated in the course. To evaluate its impact, participants completed ECG tests and a questionnaire before and after the training. Results : Post–course test scores demonstrated a significant improvement in ECG interpretation skills. Questionnaire responses indicated reduced anxiety, increased confidence, and enhanced ability to identify ischemic areas and convey findings to destination hospitals. All participants agreed that the training program would benefit their fieldwork. Conclusion : This ECG training course enhanced paramedics’ knowledge, confidence, and ability to manage patients with ACS. Continued implementation of such programs is recommended to improve prehospital care and patient prognosis.
Purpose : The revised Road Traffic Act became effective in April 2023, requiring all cyclists to “make efforts” to wear helmets. It has been three years since Oita Prefecture proactively introduced mandatory helmet use for high school students. Its effects on clinical practice were analyzed to discuss the usefulness of mandatory helmet use for high school students. Methods : The study population consisted of high school students who were involved in bicycle accidents and treated in our hospital. Their medical charts were retrospectively reviewed to compare the following data between the 3–year periods before and after the introduction of the helmet mandate: number of head injuries, severity of injury as assessed using the Abbreviated Injury Scale (AIS), transportation by ambulance, and in–hospital treatment. Results : After the introduction of the mandate, the frequency of head injuries remained unchanged compared with the pre–mandate period, however, since the introduction of the mandate, head injuries have reduced in severity, as shown by lower AIS scores. In–hospital treatment was less common, suggesting the benefits requiring of helmet use. Conclusions : Requiring a helmet use for high school students when riding a bicycle could be effective but the effects of the other ages should be verified.
A woman in her 30s was transported to the emergency department in shock, with fever as her chief complaint. Her elevated aspartate aminotransferase, alanine aminotransferase, prothrombin time, and creatinine levels indicated liver and kidney failure; therefore, she was transferred to our hospital. Although her left ventricular systolic function was preserved and there were no signs of left heart failure, she developed bradycardia caused by atrioventricular block on the second day. Coronary angiography showed no significant stenosis, while left ventriculography revealed a left ventricular ejection fraction of 48%. Right heart catheterization confirmed severe right heart failure (right ventricular stroke work index of 2.0 g·m/beat/m 2 ), suggesting liver failure secondary to right heart failure. Veno–arterial extracorporeal membrane oxygenation (V–A ECMO) was initiated for right heart support, which relieved congestion and significantly improved liver function. Swan–Ganz catheter data indicated improved right heart function, allowing for V–A ECMO withdrawal on the seventh day and the patient was discharged fully ambulatory on the 36th day. Based on the blood test results, she was diagnosed with Mycoplasma myocarditis. Right heart catheterization was instrumental in guiding circulatory support and selecting appropriate devices, while serial cardiac function evaluation using the Swan–Ganz catheter facilitated safe weaning from the circulatory support.
