[Show abstract][Hide abstract] ABSTRACT: Acute drug intoxication is one of the most important fields in emergency medicine, and the specific characteristics of the drug that caused intoxication are critical for determining the most appropriate treatment. Because it is not possible to conduct the quantitative analysis using specialized instrumentation at all medical facilities, handy screening kits that allow for the prompt determination of drug characteristics are now available in many medical facilities. However, screening kits often have limited analytical capacity, and there are false-positive and false-negative in the kits. In the present study, we examined the clinical utility of the Triage DOA® kit, as the gold standard for performing quantitative analyses. Patients participating in the study were hospitalized at the Emergency Medical Center of our institution between April 2009 and March 2013. A total of 822 cases of acute drug intoxication were analyzed using quantitative analyses and the Triage DOA®. The sensitivity, specificity, false-negative rate, false-positive rate, negative predictive value and positive predictive value of the Triage DOA® for detecting and measuring the characteristics of benzodiazepine (BZO), barbituric acid (BAR), tricyclic antidepressant (TCA) and amphetamine (AMP) were examined. The results demonstrated that, although there are some problems the Triage DOA®, it was nevertheless effective for the initial screening and treatment selection in our emergency department. However, because the positive predictive value for TCA and AMP was low and the negative predictive value for BZO was low, the results of the Triage DOA® tests should therefore be interpreted with great caution in the emergency setting. Moreover, several cases of acute drug intoxication with antipsychotics, selective serotonin reuptake inhibitor and serotonin and norepinephrine reuptake inhibitor have been reported. These drugs cannot be detected with the Triage DOA®. Therefore, it is possible that the individual being tested has used these drugs, even if the screening kit yields negative results. Physicians should therefore carefully consider this possibility when determining the initial treatment option.
[Show abstract][Hide abstract] ABSTRACT: There have been reports on patients with symptoms of crush syndrome and peripheral nerve paralysis caused by limb compression on prolonged immobilization, after administration of a psychotropic drug. However this rare case involved pulmonary embolism in addition to the clinical condition mentioned above. A 73-year-old man was receiving outpatient treatment for manic depression. A change in his medication resulted in heavy sedation, and he fell asleep for approximately 10 h in the cross-legged position. On waking, he was paralyzed in the right leg. After arrival at our hospital, a physical examination was performed, which indicated a swelling and tenderness from the right hip to the thigh, as well as sciatic nerve palsy. During the examination, the patient developed respiratory distress. Computed tomography revealed a swelling in the muscles from the right gluteus medius to the quadriceps and pulmonary embolism. Blood test results showed elevated levels of creatine phosphokinase. The patient was diagnosed with the crush syndrome and pulmonary embolism. The possibility of complication with pulmonary embolism merits careful attention in patients who present with disturbance of consciousness following drug administration, especially in those with crush syndrome caused by prolonged compression of the legs.
No preview · Article · Jan 2013 · Nihon Kyukyu Igakukai Zasshi
[Show abstract][Hide abstract] ABSTRACT: Objective:
To determine whether antithrombotic therapy with warfarin is effective and safe in patients who developed venous thromboembolism in the acute stage of polytrauma, which is associated with bleeding risk.
A retrospective study of 11 patients (8 males, 3 females; mean age, 39.8 years; injury severity score, 30.1; no fatalities) with deep venous thromboembolism and/or pulmonary embolism who were medicated with heparin and warfarin during their iCU stay.
Thrombosis was diagnosed at an average of 11.8 days after admission. Thrombus formation was confirmed in pulmonary arteries in 5 cases and in deep veins in 9 cases. Diagnosis was based on Doppler ultrasound findings in 6 cases and on computed tomography findings in 5 cases. anticoagulant therapy was used in 10 cases, but not in 1 case with cerebral contusion. approximately 33 days after starting anticoagulant therapy, thrombi had disappeared or were reduced in size in 9 of 10 patients with no complications observed.
Heparin and warfarin therapy cleared deep vein and pulmonary artery thrombosis after polytrauma without any bleeding complications. Further studies are necessary to determine the safe anticoagulant dosage and duration for rapid thrombus removal.
No preview · Article · Dec 2012 · The Tokai journal of experimental and clinical medicine
[Show abstract][Hide abstract] ABSTRACT: Burns sustained in bathtubs are a social and medical problem in Japan, especially among the elderly. Between October 2003 and March 2009, 22 adult scald burn patients (men, 17; average age, 65.3 ± 21.2 years) were transferred to Tokai University. In this study, we investigated the characteristics of these patients, and compared clinical parameters among patients with burns sustained in a bathtub (n = 10) and those with burns sustained due to other causes (n = 12). The average percentage total body surface area (%TBSA), dermal and deep burn area, and abbreviated burn severity index (ABSI) were 27.6 ± 23.8, 19.9 ± 20.5%, 7.8 ± 13.1%, and 7.7 ± 3.1, respectively. All patients in the bathtub burn group were elderly, 6 developed internal diseases, 3 had alcohol-related burns, and 4 died. Additionally, their %TBSA and ABSI were higher than those of the non-bathtub burn group patients. Burns sustained in bathtubs were more severe than those sustained due to other causes. The bathtub-related burn patients were elderly, and their burns were extensive and deep; hence, they were at a higher risk of developing internal diseases. Thus, introduction of safer bathing styles and bath systems will decrease incidences of bathtub-related burns.
No preview · Article · Dec 2010 · Burns: journal of the International Society for Burn Injuries
[Show abstract][Hide abstract] ABSTRACT: The lifesavers responsible for lifesaving at the waterside routinely undergo cardiopulmonary resuscitation (CPR) training, but in Japan, they are considered as lay persons. Lifesavers are likely to have better basic life support skills than lay persons. The objective of this study is to demonstrate that the accuracy of carotid pulse checks by lifesavers is not inferior to that of paramedics and is superior to that of lay persons by using CPR training mannequins.
This was an observational study in which the subjects included 48 lifesavers certified by the Japan Lifesaving Association, as well as 16 paramedics and 15 lay persons. The accuracy of the examinees' answers and the time taken to answer in the 3 groups were compared. The accuracy rate was 93% in lifesavers, 94% in paramedics, and the difference was not significant (P=1). The accuracy rate of the lay persons' answers was 63%, with significant differences between this group and the lifesavers (P<0.001) and the paramedics (P<0.001). The average time taken to answer the questions was 6.6 s for the lifesavers and 7.0 s for the paramedics, and the difference was not significant (P=0.44). The average time taken to answer the questions from the lay persons group was 20.5 s, with significant differences between this group and the lifesavers (P<0.001) and the paramedics (P<0.001).
The results of this evaluation, using CPR-training mannequins, to test the accuracy of carotid pulse checks by lifesavers were equivalent to those of paramedics and superior to those of lay persons.
No preview · Article · Sep 2010 · Circulation Journal
[Show abstract][Hide abstract] ABSTRACT: In Japan, intravenous nifekalant (NIF) was often used for direct current cardioversion-resistant ventricular fibrillation (VF), until the use of intravenous amiodarone (AMD) was approved in 2007. The defibrillatory efficacy of NIF and AMD has thus far not been compared for resuscitation.
Between August 2007 and April 2009, 403 consecutive out-of-hospital patients with cardiopulmonary arrest were transferred to the Emergency Medical Service of Tokai University. Of these, 30 patients with first defibrillation failure or VF recurrence were enrolled for this NIF/AMD study. The final defibrillation success (and hospital survival rate) was 67% (10/15) in the AMD and 47% (7/15) in the NIF group. The discharge survival rate was 53% (8/15) in the AMD and 21% (4/15) in the NIF group (P = 0.06). Notably, all 4 survivors in the NIF group could take up normal daily life again, whereas this was restricted to only 2 patients from the 11 survivors in the AMD group. The difference is probably partly attributable to longer time from AMD administration to defibrillation success compared with NIF. In the cases of defibrillation failure, VF continued in 4/8 by NIF, however, asystole or pulseless electrical activity occurred in 4/5 patients by AMD.
AMD may be borderline superior over NIF to facilitate defibrillation in out-of-hospital patients with cardiopulmonary arrest. However, from the view point of preservation of brain function, NIF is not inferior to AMD for CPR.
No preview · Article · Feb 2010 · Journal of cardiovascular pharmacology
[Show abstract][Hide abstract] ABSTRACT: In Japan, there has recently been a severe shortage of physicians in regional core hospitals, limiting the acceptance of emergency patients. Searching for available medical institutions over an extended area beyond the regular regional medical area should increase the possibility of finding medical institutions capable of accepting patients. Physician staffed helicopter ambulance system, so called the Doctor-Helicopter service is highly effective in saving patients life, since emergency doctors start to treat patients at the scene. It may be also useful to transport the critically ill patients for a long distance. A 29 year old female diagnosed twin fetus with twin-twin transfusion syndrome needs urgent delivery at about 29 weeks of gestation. The patients had to be transported to the perinatal care center which is 160 km from the hospital to where the patient was admitted because of a lack of NICU. During transportation, the maternal vital signs were stable without cervical dilatation. After arrived at the perinatal center, the patient underwent Caesarian section. Both babies had respiratory distress syndrome and admitted to NICU. With increasing cases in which medical institutions cannot accept peripartum emergency patients, it needs to search for medical institutions over an extended area and transport patients by Doctor-Helicopter.
Full-text · Article · Jan 2010 · The Tokai journal of experimental and clinical medicine
[Show abstract][Hide abstract] ABSTRACT: Heart injury due to electric shock is currently diagnosed based on electrocardiogram (ECG) changes or elevated levels of myocardial enzymes or both. However, the rate at which ECG detects abnormalities is very low; thus, the estimated rate of the diagnosis of myocardial damage due to electric shock is lower than the actual rate. The method of nuclear medicine study of the heart is superior with regard to evaluating transient ischemia, such as angina pectoris, in patients whose ECG and myocardial enzyme levels are normal. Therefore, we attempted to diagnose transient myocardial damage in electric shock patients by using nuclear medicine study of the heart.
No preview · Article · Apr 2009 · The Journal of trauma
[Show abstract][Hide abstract] ABSTRACT: Accidental deep hypothermia (ADH)--a condition in which the core body temperature is less than 28 degrees C--is a medical emergency; the mortality rates for ADH remain high. The efficacy of cardiopulmonary bypass (CPB) rewarming has been proved in ADH patients with cardiopulmonary arrest; however, its efficacy in the ADH patients without cardiopulmonary arrest remains controversial. In our study, we evaluated the efficacy of portable percutaneous cardiopulmonary bypass (PPCPB) for rewarming and providing cardiovascular support in the hemodynamically unstable ADH patients without cardiopulmonary arrest.
Between April 2001 and March 2006, we performed a retrospective study at Tokai University, Kanagawa, Japan. We studied 24 ADH patients without cardiopulmonary arrest (male:female ratio, 15:9; mean age, 68.5 +/- 12.9 years) with hemodynamic instability who had not developed intracranial hemorrhage. We evaluated the efficacy of PPCPB rewarming by estimating the mean time of initiation of PPCPB after admission, rewarming speed, the success rate of rewarming, the rate of weaning from PPCPB, the incidence of ventricular fibrillation (Vf) during rewarming, complications associated with PPCPB, mortality rate, and the Glasgow Outcome Scale (GOS) scores of the patients who survived.
The mean time of initiation of PPCPB after admission was 41.9 +/- 7.9 minutes. The rewarming speed was 4.0 +/- 1.5 degrees C/h. A 100% success rate was achieved after the rewarming procedure, whereas the rate of weaning from PPCPB was 91.7%. Vf during rewarming developed in one case; however, electrical defibrillation was possible. No direct complications of PPCPB were observed. The mortality rate was 12.5% (3/24). The GOS scores of the patients who survived were as follows: 5 points, 17 cases; 4 points, 3 cases; and 3 points, 1 case.
PPCPB rewarming is a clinically efficacious procedure for rewarming and providing cardiovascular support in hemodynamically unstable ADH patients without cardiopulmonary arrest who have not developed intracranial hemorrhage.
No preview · Article · Jan 2009 · The Journal of trauma
[Show abstract][Hide abstract] ABSTRACT: A rapid headspace solid-phase microextraction-gas chromatography-mass spectrometry (HS-SPME-GC-MS) method has been developed for the determination of metaldehyde in human serum samples. Metaldehyde is extensively used as a molluscicide for the control of slugs and snails, and cases of metaldehyde poisoning have been reported. Metaldehyde was headspace-extracted on a polydimethylsiloxane (PDMS) fiber at 70 degrees C for 25 min, desorbed, and analyzed rapidly by GC-MS. The method was validated for limit of detection (LOD), linearity, precision, and recovery. Although the recovery of the sample was very low, the method itself was rapid with a low detection limit of 0.25 microg/ml, R.S.D. value 12.6%, and linearity range 0.5-25.0 microg/ml (r(2)=0.999). The results demonstrated that the SPME-GC-MS method for the analysis of metaldehyde is simple, rapid, solvent-free, and does not require any pre-analysis conversions.
No preview · Article · Nov 2008 · Journal of Chromatography B
[Show abstract][Hide abstract] ABSTRACT: This paper describes an assay for the determination of glyphosate (GLYP), glyphosate metabolites [(aminomethyl) phosphonic acid] (AMPA), and glufosinate (GLUF) in human serum. After protein precipitation using acetonitrile and solid-phase extraction, serum samples were derivatized and analyzed by gas chromatography-mass spectrometry (GC-MS). The assay was linear over a concentration range of 3-100.0 microg/ml for GLYP, AMPA, and GLUF. The overall recoveries for the three compounds were >73%. The intra- and inter-day variations were <15%. Precision and accuracy were 6.4-10.6% and 88.2-103.7%, respectively. The validated method was applied to quantify the GLYP and AMPA content in the serum of a GLYP-poisoned patient. In conclusion, the method was successfully applied for the determination of GLYP and its metabolite AMPA in serum obtained from patient of GLYP-poisoning.
No preview · Article · Oct 2008 · Journal of Chromatography B
[Show abstract][Hide abstract] ABSTRACT: We aimed to evaluate prognostic factors and toxicokinetics in acute fenitrothion self-poisoning.
We reviewed 12 patients with fenitrothion self-poisoning admitted to the intensive care unit between 2003 and 2006. We compared the characteristics, initial vital signs, physiological scores, corrected QT interval on electrocardiogram and laboratory data (serum fenitrothion concentration and cholinesterase activity) of non-survivors and survivors. Furthermore, we evaluated the correlation between the prognostic factors and severity of poisoning (lengths of intensive care unit and hospital stays), and the toxicokinetics of the patients.
In the 2 non-survivors, the estimated fenitrothion ingestion dose and the serum fenitrothion concentration at the emergency department and at 24 h after ingestion were significantly higher than those in the 10 survivors. (P = 0.008, 0.003, and 0.04, respectively). In the 10 survivors, the serum fenitrothion concentration at 24 h after ingestion was significantly correlated with the lengths of intensive care unit and hospital stays (P = 0.004 and 0.04, respectively); however, the initial vital signs, physiological scores, corrected QT interval on electrocardiogram at the emergency department, and serum cholinesterase activity did not show any correlation. In five patients successfully fitted to a two-compartment model, the distribution and elimination half-lives were 2.5 and 49.8 h, respectively, which is compatible with the slow and prolonged clinical course of fenitrothion poisoning. CONCLUSION. Estimated fenitrothion ingestion dose and serum fenitrothion concentration at the emergency department and at 24 h after ingestion may be useful prognostic factors in acute fenitrothion self-poisoning. Furthermore, we should take care for the patients whose serum fenitrothion concentration is high.
No preview · Article · Aug 2008 · Clinical Toxicology
[Show abstract][Hide abstract] ABSTRACT: Inflammatory pseudotumor (IPT) is a benign tumorous lesion of unknown cause, which is composed of fibrous tissue with infiltration of plasma cells and lymphocytes. A 57-year-old male with gastritis was indicated to have hepatic dysfunction during observation of the course of gastritis at a nearby hospital. He was referred to our facility to undergo detailed examinations. When he visited our hospital for the initial examination, he had no subjective symptoms. His past medical history was unremarkable. There were no distinct abnormalities on the medical examination. Blood tests revealed a white blood cell count of 10400 / L, CRP of 0.29 mg/dl, AST of 31 IU/L, ALT of 46 IU/L, ALP of 583 IU/L and -GTP of 408 IU/L, showing a mild inflammatory reaction and elevated hepatobiliary enzymes. Abdominal ultrasonographic examination revealed a tumor mass approximately 4 cm in diameter in a lateral hepatic segment. The margin and center of the mass were hypoechoic and iso- to hyperechoic, respectively, and the inside of the mass was non-homogeneous. Needle biopsy revealed only inflammatory findings with no indications of malignancy. Since computed tomography (CT) of the abdomen, done 4 months after detection of the tumor mass, revealed the mass to have increased to approximately 6 cm in diameter, excision biopsy was considered. The CT taken 2 months later revealed the mass to have regressed to approximately 2 cm in diameter, but excision of the lateral hepatic segment was undertaken at the patient's request. As a result, the diagnosis of IPT of the liver was confirmed. Imaging findings of hepatic IPT are variable and specific findings are lacking. Since the rate of correct diagnosis with needle biopsy is also low, IPT of the liver is often very difficult to differentiate from malignant tumors. On the other hand, since it may show spontaneous regression, indications for surgery must be assessed very carefully.
Preview · Article · Jan 2008 · The Tokai journal of experimental and clinical medicine
[Show abstract][Hide abstract] ABSTRACT: Heat stroke is often complicated by hepatic dysfunction as a manifestation of multiple organ dysfunctions, but acute hepatic failure rarely progresses to become the major morbid condition of heat stroke. We encountered a case who survived life-threatening classic heat stroke; the patient developed this condition, subsequently associated with acute hepatic failure, while bathing at home. A 73-year-old man was found in the bath in his home with unconsciousness, and was transferred to a nearby hospital. At the time he was in a coma, but no remarkable abnormalities were detected on blood examination. Rubor of his entire body beneath the cervical region was recognized. Under the diagnosis of a burn with consciousness disturbance, he was referred and transferred to our hospital. He was comatose and his axillary body temperature was 39.7°C. His consciousness improved after admission, but blood examination revealed rhabdomyolysis, DIC and hepato-renal dysfunction. Subsequent blood examination findings showed rapid exacerbation. On the 2nd hospital day, PT% was 12, INR was 4.8. On the 3rd hospital day, serum ALT was elevated to 3,873 U/L, and the patient had hyperammonemia. On the 13th hospital day, serum total bilirubin was elevated to 33 mg/dl. Thereafter, additional conservative treatment produced gradual recovery of hepatic function.
Preview · Article · Jan 2008 · The Tokai journal of experimental and clinical medicine
[Show abstract][Hide abstract] ABSTRACT: A 41-year-old female attempted suicide by taking 7.8g acetaminophen and was transferred to our hospital four hours after ingestion. The patient was diagnosed as non-hepatic toxicity (below the line set by the Rumack Matthew nomogram). Laboratory data showed an elevation in serum liver enzymes and coagulation defects at 3 days after ingestion, therefore, the patient was treated with plasma exchange and an oral administration of N-acetylcysteine (NAC). The elevation of liver enzymes was maximal at 4 days after ingestion, and the laboratory data became normalized at approximately 9 days after ingestion. In this case, habitual alcohol intake may have exacerbated the severe liver injury. We should consider an exacerbation of hepatotoxicity and administer NAC in any case having a history of habitual alcohol intake, even if the case was diagnosed as non-hepatic toxicity by the nomogram.
No preview · Article · Aug 2006 · Chūdoku kenkyū: Chūdoku Kenkyūkai jun kikanshi = The Japanese journal of toxicology
[Show abstract][Hide abstract] ABSTRACT: In Japan, the physician staffed helicopter ambulance system, "Doctor-Heli" System, was first founded in our University Hospital in 1999. In this system, a helicopter is based at an Emergency Medical Center at all times and dispatch with both emergency physicians and a nurse upon a request by paramedics. This system has made possible a critically earlier development of the initial management at the point of care and rapid transport to the hospital. We presented the case suffering from acute cerebral infarction was transported by the "Doctor-Heli" and received the intervention for thrombolysis successfully. It was less than three hours from the onset to the completion of the intervention. The "DoctorHeli" system has a potential benefit for patients with acute cerebral infarction because of it enables quite early clinical diagnosis and rapid transport.
No preview · Article · Aug 2005 · The Tokai journal of experimental and clinical medicine
[Show abstract][Hide abstract] ABSTRACT: We report a case of isolated brain stem injury caused by the tentorium cerebelli. A 17-year-old male was admitted to our hospital. Thirty minutes before admission, he was struck by another motorcycle while driving his own motorcycle. The Glasgow Coma Scale (GCS) was 10. He had no extremity weakness and his pupils were normal. CT scan showed no evidence of intracranial lesions except for facial bone fractures. His consciousness level improved to GCS 13 at 6 hours after admission. Follow-up CT scan was normal, however MRI 3 days after admission showed a contusion at the left lateral midbrain. He was discharged without any neurological deficits on 6 days after admission. Analysis of the distance between the brain stem and the tentorial margin using MR cisternography showed that the left side was shorter than the right side. We presumed that an isolated lateral brain stem injury was caused by the direct impact of the tentorium cerebelli. Typically the location of this type of lesion is present in the same side as that of impact. However in this case the orientation was opposite to that. We considered that the distance between the brain stem and the tentorial margin affected the mechanism of this lesion.
No preview · Article · Mar 2004 · No shinkei geka. Neurological surgery
[Show abstract][Hide abstract] ABSTRACT: A 48-year-old woman presented after taking 2000 mg of selenium dioxide, corresponding to 10 times the experimental lethal dose in animals. She presented with mildly altered consciousness and hematemesis. Endoscopy revealed mucosal damage throughout the oral cavity, esophagus, and stomach. There was no evidence of perforation. After intubation and gastric lavage, hemodialysis was performed. The patient was discharged uneventfully on the 16(th) day. This case highlights a very rare acute selenium intoxication. Serum and urinary selenium levels and serum glutathione peroxidase activities during the patient's course were followed, as well as the mucosal corrosive damage caused by the selenium.
No preview · Article · Mar 2004 · Journal of Emergency Medicine