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BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

<h4>Introduction</h4>Traumatic tension gastrothorax is a type of obstructive shock similar to tension pneumothorax. However, tension gastrothorax is not well known among emergency physicians, and no consensus has yet been reached on management during initial trauma care. We present a case of traumatic tension gastrothorax in which tube thoracostomy was performed based solely on clinical findings very similar to tension pneumothorax, followed by emergency laparotomy.<h4>Presentation of case</h4>A 24-year-old male motorcyclist was brought to our emergency medical center after being struck by a motor vehicle. He was in respiratory failure and hypotensive shock with findings suggestive of pneumothorax. Although the physical findings were not fully in line with tension pneumothorax, we immediately performed finger thoracostomy. Subsequent radiography revealed left diaphragmatic rupture with hernia. After unsuccessful attempts to decompress the stomach with a nasogastric tube, immediate emergency laparotomy was performed. During the operation, the stomach, which had prolapsed through the ruptured diaphragm into the thoracic cavity, was manually returned to the abdominal cavity. The ruptured diaphragm was repaired with sutures.<h4>Discussion</h4>Although distinguishing between tension pneumothorax and tension gastrothorax based on physical examination alone is difficult, tension gastrothorax requires careful attention to avoid intrapleural contamination from gastric injury. In addition, relying solely on stomach decompression with a nasogastric tube or delaying laparotomy could lead to cardiac arrest.<h4>Conclusion</h4>When tension pneumothorax is suspected during initial trauma care, tension gastrothorax should also be considered as a differential diagnosis and treated with immediate diaphragmatic repair once identified.

症例は67歳男性。ダンプカーを運転中,他のトラックに追突し受傷した。来院時ショック状態であったが輸血により改善したため外傷パンスキャンCTを施行した。CTでは,腸間膜の血管外漏出像を認めたため緊急開腹止血術を行った。手術では腸間膜に複数の動脈性出血と横行結腸穿孔を認め,止血術と横行結腸部分切除を行った。腹部コンパートメント症候群の危険因子である大量輸血,腹腔内感染,肥満を認めたため,一期的な閉腹は行わずOpen Abdominal Management(OAM)を開始した。初回手術から8日後,4回目の手術を行い炎症による腸管浮腫で閉腹が困難であったことから,陰圧閉鎖療法を併用したMesh mediated fascial tractionを導入し,20日後に一次筋膜閉鎖を達成した。陰圧閉鎖療法を併用したMesh mediated fascial tractionは,重症腹部外傷などでOAMを行い閉腹困難となった症例に対する閉腹方法の選択肢となる術式と考えられた。(著者抄録)

Background: This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI). Methods: This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR). Results: A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50–4.16 and AOR: 4.98; 95 % CI, 2.75–9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries. Conclusion: Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies. Level of Evidence: Level 4; Therapeutic/Care management.

症例は54歳男性。仕事中に鉄パイプの下敷きになり受傷した。CT検査で,鈍的外傷によると思われる左肺ヘルニア,左多発肋骨骨折,左血気胸,左肺挫傷,骨盤および左右大腿骨骨折,左腰椎横突起骨折と診断した。胸部損傷に対して左胸腔ドレーンを挿入して経過をみた。大腿骨骨折と骨盤輪骨折に対して固定術を行い,経過良好で入院50日目に転院した。肺ヘルニアは入院36日目のCT検査では還納されていたが,受傷から約7ヵ月後のCT検査で再発していた。その後の治療方針について呼吸器外科とも協議し,局所症状や呼吸器症状はないため,患者に説明のうえで経過をみる方針となり,受傷後約1年の現在まで無症状に経過している。外傷性肺ヘルニアは比較的まれな損傷形態で,病態によっては脱出と還納を繰り返す可能性から治療方針に苦慮することがある。いまだ定石はないがリスク・ベネフィットを考慮して方針を決める必要があると考えられる。(著者抄録)

BACKGROUND: In recent years, various home-use health devices have gained popularity. The abdominal roller is one of these. Spinal cord injury without radiological abnormality is known to occur even with relatively minor injuries, but there are few reports of such injuries caused by a roller. CASE PRESENTATION: Two cases of spinal cord injuries caused by a roller are reported. In both cases, injuries occurred during the standing rollout by a patient in an inebriated state, and the patients were rushed to an emergency department. CONCLUSION: Because the use of abdominal rollers may result in extremely serious disabilities, it is necessary to emphasize the appropriate use of such equipment.

目的:コロナ禍における事後検証会開催の工夫について報告する。方法:e-learningシステムを用いた事後検証会の導入前後,およびコロナ禍における事後検証会開催方法について,参加者にアンケート調査を行い,各々の開催方法による満足度を調査した。結果:128件の回答を得た。e-learningシステム導入前の対面式では40.9%が満足・どちらかといえば満足と回答,対面式+ビデオ視聴形式では64.5%が満足・どちらかといえば満足と回答,完全web形式(メーリング討議)では56.3%が満足・どちらかといえば満足と回答した。結論:それぞれの開催形式にはメリット・デメリットがあるが,対面式+ビデオ視聴形式のハイブリッド開催は事後検証会の活発な討議に有効であると考えられる。(著者抄録)

BACKGROUND Centipede envenomation is usually mild, but a review of the existing literature revealed a more serious course in a small proportion of patients. In fact, necrotizing soft-tissue infections have been reported following centipede stings in a small number of cases and require early diagnosis and treatment because of a high mortality rate. CASE REPORT A 78-year-old man was stung by a centipede on the left abdomen. Treatment with antimicrobial agents was started due to cellulitis, but extensive erythema developed from the left chest to the left buttock. Six days after being stung, he visited our hospital. Necrotizing soft-tissue infection was diagnosed and treated immediately with antibiotics and debridement on the left side of the abdomen and chest. Group A Streptococcus was detected in the fascia. The wound was left partially open and washed daily, resulting in gradual improvement of the wound condition. On hospitalization day 8, the open wound was able to be closed. Antimicrobial therapy was completed on hospitalization day 16. The patient showed good progress. CONCLUSIONS Centipede stings are not rare in tropical and subtropical regions, and most occurrences of centipede envenomation cause only local symptoms. However, we believe that even wounds caused by centipedes should be monitored, given the possibility of subsequent severe infection, as in the present case. In addition, the causative organisms identified in the present patient with necrotizing soft-tissue infection following a centipede sting were commensal bacteria of the skin. Future research is thus needed to clarify the relationship between these causative organisms and centipedes.

50歳代男性。トラックを運転中, 停車していたトラックに追突して受傷した。精査のComputed tomography (CT) にて両側外傷性気胸・骨盤骨折に加えて左総頸動脈の造影途絶を認めた。左内頸動脈および左外頸動脈は造影されていた。頭蓋内に梗塞所見はないため慎重に経過観察していたが, 来院14時間後に右片麻痺と意識レベルの低下が出現した。magnetic resonance imaging (MRI) で左中大脳動脈領域の脳梗塞を認めた。骨盤骨折の手術後から抗凝固療法を開始した。失語と麻痺は残存したが神経症状は増悪なく経過し, 約2カ月後に転院した。鈍的外傷による総頸動脈閉塞はまれな疾患であるが, 神経症状出現率・死亡率がともに高率である。治療として抗血小板薬の有用性が報告されているが, 多発外傷の患者においては出血増悪によるリスクも加味する必要があり, 治療には今後さらなる検討が必要と考えられた。

75歳、男性。ハチ酒造りを趣味とし、これまで多数回のハチ刺傷歴があるが症状を呈したことはなかった。某日スズメバチに両肩を2ヶ所刺傷された後、意識消失した。血圧低下・頻呼吸・全身の膨疹を認め、アナフィラキシーショックとしてアドレナリンを筋注され当院に搬送となった。病着したとき、呼吸・循環動態は安定していたため、経過観察を目的に入院し翌日に退院した。ハチ刺傷によりアナフィラキシーショックをきたすことはよく知られ、通常は2度目以降の刺傷により発症率が増加すると思われる。一方で複数回の刺傷において無症状であればその危険性は低下していると考えられやすい。しかし本症例は多数回の刺傷歴があるものの無症状で経過し、今回に限りアナフィラキシーを発症した。残念ながらその機序を説明する所見を得ることはできなかったが、このような症例が存在することの重要性に鑑みここに報告する。(著者抄録)

BACKGROUND: The management of cardiac trauma requires rapid intervention in the emergency room, facilitated by a surgeon with prior experience to have good outcomes. Many surgeons have little experience in the requisite procedures. We report here 4 patients who suffered cardiac trauma, and all 4 patients survived with good neurologic outcomes. CASE PRESENTATIONS: Patient 1 suffered blunt cardiac trauma from a motor vehicle accident and presented in shock. Cardiac tamponade was diagnosed and a cardiac rupture repaired with staples through a median sternotomy after rapid transport to the operating room. Patient 2 suffered blunt cardiac trauma and presented in shock with cardiac tamponade. Operating room median sternotomy allowed extraction of pericardial clot with recovery of physiologic stability. Patient 3 presented with self-inflicted stab wounds to the chest and was unstable. She was brought to the operating room and thoracotomy allowed identification of a left ventricle wound which was repaired with a suture. Patient 4 presented in cardiac arrest with multiple self-inflicted stab wounds to the chest. Emergency room thoracotomy allowed repair of a right ventricle laceration with recovery of vital signs. CONCLUSIONS: The management of all 4 patients was according to the principles taught in the ATOM course. Three of the 4 surgeons had no prior experience with management of cardiac trauma and credited the good outcomes to taking the ATOM course. These are uncommon injuries and formal training in their management is beneficial to patients.

A 75-year-old pedestrian was struck by a truck and in shock with both lower extremities significantly deformed, with injuries extending proximally to the inguinal region and degloving injuries. Resuscitative endovascular balloon occlusion of the aorta was performed to achieve temporary hemostasis and the patient became hemodynamically stable. Following stabilization, both lower extremities were amputated. Resuscitative endovascular balloon occlusion of the aorta may be effective to achieve temporary hemostasis in patients with extensive injuries of the lower extremities, especially with extension to the inguinal region which precludes use of a tourniquet.

Accidental hypothermia is the state in which body temperature falls due for exposure to a chilly environment. In accidental hypothermia, the mortality rate is higher the lower the body temperature. We report a case of a consciousness disorder and severe hypothermia, with a body temperature below 28°C, in which it later became clear that a cervical spinal cord injury had been caused by a small external force. A 70-year old woman was transported to our hospital in an ambulance for consciousness disturbance and severe hypothermia. At the time of arrival, her rectal temperature was 26.2°C. We promptly performed rewarming. Her consciousness level became clear, but paralysis and diminished sensation were observed below the C5 domain. We suspected cervical spinal cord injury and performed cervical magnetic resonance imaging. She was diagnosed as having C5 cervical spinal cord injury. When there is a consciousness disorder due to accidental hypothermia, it might not be possible to evaluate the neurological value of the cervical spinal cord injury correctly. The presence of cervical spinal cord injury should be considered when patients have a decreased consciousness level due to hypothermia.

Background. Glufosinate ammonium has a famous delayed complication as respiratory failure, however, delayed cardiogenic complication is not well known. Objectives. The aim of this study is to report a takotsubo cardiomyopathy as a delayed complication of glufosinate ammonium for suicide attempt. Case Report. A 75-year-old woman ingested about 90 mL of Basta, herbicide for suicide attempt at arousal during sleep. She came to our hospital at twelve hours after ingesting. She was admitted to our hospital for fear of delayed respiratory failure. Actually, she felt down to respiratory failure, needing a ventilator with intubation at 20 hours after ingesting. Procedure around respiratory management had smoothly done with no delay. Her vital status had been stable, however, she felt down to circulatory failure and diagnosed as Takotsubo cardiomyopathy at about 41 hours after ingestion. There was no trigger activities or events to evoke mental and physical stresses. Conclusion. We could successfully manage takotsubo cardiomyopathy resulted in circulatory failure in a patient with glufosinate poisoning for suicide attempt. Takotsubo cardiomyopathy should be taken into consideration if circulatory failure is observed for unexplained reasons. © 2012 Keiichiro Tominaga et al.