田中 保平

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.

Introduction: 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. Presentation of case: 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. Discussion: 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. Conclusion: 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)

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 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。

骨髄路確保は重度患者に対する処置として重要だが、研修医が学習する機会は少ない。今回、当院救急科で研修した36人の研修医を対象にブタの胸骨に骨髄針を挿入するシミュレーションを行い、その前後にテストとアンケートを実施してその結果を評価した。シミュレーションでの骨髄路確保の成功率は100%だった。理解度テストの結果は、9.2±0.94(平均±標準偏差)から9.6±0.79に改善された(満点10、P=0.017)。骨髄針に関するアンケートの点数は7.4±2.9から14±1.3に増加した(満点15:P<0.0001)。特に自己効力感に関するスコアは1.8±0.91から4.1±0.64に増加した(満点5、P<0.0001)。このシミュレーションで骨髄路確保に関する知識・理解・自己効力感が向上した。本トレーニングにより、骨髄路確保がより良くできる可能性がある。(著者抄録)

症例は40歳代男性。仕事中に弾き飛ばされた3kgのアルミ塊が胸腹部に当たり受傷した。造影CTで肝内側区域に著明な血管外漏出像を伴う日本外傷学会分類IIIbの肝損傷を認めた。経カテーテル動脈塞栓術で肝動脈の一部を塞栓して止血が得られたため, 非手術治療 (以下NOM) を選択した。しかし入院6日目に胆汁性腹膜炎を併発し, 開腹ドレナージとENBD留置を行い, いったん全身状態は改善した。その後, 腹痛と発熱が再燃し, CTで肝壊死と肝膿瘍を認めたため経皮的ドレナージを施行したが, ドレナージ後も胆汁漏は持続したため肝左葉切除術を施行し, 最終的に良好な経過を得た。 肝損傷に対するNOMの成功率は高いが, NOM中に合併症のため手術が必要になる症例も存在する。特に重症度が高い損傷は合併症の頻度が高く, 手術が必要となる可能性も高いため, 厳重な経過観察と機を逃さぬ対応が必要なことを改めて認識した。

A 77-year-old man was admitted to a regional hospital to undergo investigation of abnormal electrocardiographic findings. Coronary angiography revealed 99% stenosis of the right coronary artery(RCA) segment 3 and 75% stenosis of the left anterior descending artery (LAD)segment 7. Left ventriculography revealed an aneurysm at the inferior wall of the left ventricle. On computed tomography and echocardiography, a saccular aneurysm at the inferior wall, 15 mm in diameter, was observed. Under the suspicion of a ventricular false aneurysm resulting from myocardial infarction, aneurysmectomy, patch closure of the aneurysmal orifice and coronary artery bypass grafting to the LAD and RCA were performed. No pericardial adhesion to the ventricular aneurysm was observed. His postoperative course was uneventful, and he was discharged from the hospital on the 28th postoperative day in good condition. The pathological examination revealed residual cardiomyocytes with the aneurysmal wall.