Usefulness of Computed Tomography in the Diagnosis of an Overdose

Computed tomography (CT) is superior for the detection of substances with low radiolucency in comparison with abdominal roentgenograms. In the present study, medical chart review was retrospectively performed for patients who were admitted and underwent plain CT including the stomach on arrival to investigate whether CT is useful for diagnosing overdose (OD). The subjects were divided into patients with OD who did not undergo gastric lavage (OD group) and those without OD (Control group). The presence of a radiopaque area (Hounsfield number over 100 on a range of interest of 3mm2) in the stomach on CT was defined as a positive finding. The average Glasgow Coma Scale in the OD group (n＝11) was significantly lower than that in the Control group (n＝137). Positive findings on CT were found more frequently in the OD group than in the Control group (100 vs. 19.7%, p＜0.0001). Based on the finding of a high-density deposition in the bottom of the stomach, the CT predicted OD with 98.5% specificity. Accordingly, CT findings of a high-density deposition in the stomach of a patient with a diminished consciousness may suggest the presence of a recent overdose

Muscle-specific tyrosine kinase-antibody-positive myasthenic crisis with detailed electrophysiologic studies.

A 69-year-old male who presented in a coma due to sudden respiratory arrest was transferred to our hospital. After endotracheal intubation with manual ventilation, he became alert and his neurologic findings were within the normal range, except for palsy of the respiratory muscles. Biochemical analyses of the blood and brain computed tomography failed to indicate the cause of the respiratory arrest. An edrophonium test did not improve the respiratory arrest. An urgent electromyogram at the dorsal interossei, biceps, and sternocleidomastoideus muscle and a repetitive nerve stimulation test at the trapezius and deltoid muscle were also negative on the first hospital day. However, on the 16th day in the hospital, a repetitive nerve stimulation test at the levator labii superioris alaeque nasi showed a waning phenomenon. This result indicated a diagnosis of myasthenia gravis. Anti.muscle-specific tyrosine kinase antibody was found to be positive. After treatment with plasmapheresis and prednisolone, he regained normal respiratory function. Anti.muscle-specific tyrosine kinase (MuSK)-antibodypositive myasthenia gravis (MG) (MuSK-MG) tends to be associated with a lower incidence of a positive edrophonium test, a lower incidence of a positive electrophysiologic study excluding the face, and a higher incidence of respiratory failure in comparison to anti.acetylcholine receptors (AchR)-antibody-positive MG (AchR-MG). Respiratory failure is curable with treatment. Accordingly, in addition to obtaining a precise diagnosis, an emergency physician should recommend an electrophysiologic study including the face to make a differential diagnosis for respiratory arrest when biochemical and radiologic studies fail to indicate the cause of the respiratory arrest

Inhaled steroid therapy and hospitalization for bronchial asthma : trend in Tokushima University Hospital

With the recognition that airway inflammation is present even in patients with mild bronchial asthma, therapy with inhaled corticosteroids is now indicated in various stages of patients. In the present article, we retrospectively examined the prescriptions for inhaled corticosteroids and other drugs for the treatment of outpatients with bronchial asthma at Tokushima University Hospital. We also analyzed asthma control in these patients, in terms of the incidence of emergency consultations and hospitalizations due to asthma exacerbations. To analyze the recent trend, the patients observed from 1998 to 2000 (recent years) were included, and for control purpose, those in 1990 and 1991 (earlier years) were also included. The percentage of patients treated with inhaled corticosteroids remarkably increased in recent years (mean 81.3%) compared to earlier years (mean 23.5%). In contrast, the usage of oral corticosteroids, oral xanthine derivatives, β2-adrenergic receptor agonists and anti-allergic agents tended to decrease in the 10 years period. After the introduction in 1995, considerable patients up to 25% have been treated with anti-leukotrienes. Emergency consultations decreased in recent years (mean 0.18/patient/year) compared to earlier years (mean 0.79/patient/year). Emergency hospitalizations also decreased in recent years (mean 0.043/patient/year) compared to earlier years (mean 0.23/patient/year).In the present study, spread of inhaled corticosteroid therapy and decline in incidence of emergency consultation and hospitalization were simultaneously observed at Tokushima University Hospital, and the former has, at least in part, a contribution to the latter

Significance of the carboxyhemoglobin level for out-of-hospital cardiopulmonary arrest

Background: At low concentrations, carbon monoxide (CO) can confer cyto and tissue-protective effects, such as endogenous Heme oxygenase 1 expression, which has antioxidative, anti-inflammatory, antiproliferative, and antiapoptotic effects. The level of carboxyhemoglobin in the blood is an indicator of the endogenous production of CO and inhaled CO. Aim of study: To investigate the significance of the value of carboxyhemoglobin for out-of-hospital (OH) cardiopulmonary arrest (CPA). Materials and Methods: This study involved a medical chart review of cases treated from January to December 2005. The inclusion criteria included a patient who was transported to this department due to an OH CPA. The exclusion criteria included a patient who did not undergo blood gas analysis on arrival and who experienced CPA due to acute carbon monoxide intoxication. The subjects were divided into two groups based on their final outcome of either survival or non-survival. Results: There was no significant difference associated with the sex, age, frequency of witness collapse, bystander cardiopulmonary arrest, electrocardiogram at scene, cause of CPA, value of PCO 2 , HCO3 - , and methemoglobin. The frequency of OH return of spontaneous circulation and the value of pH, PO 2 , base excess, and carboxyhemoglobin in the survival group were greater than those values in the non-survival group. There were no subjects whose carboxyhemoglobin level was 0% on arrival in the survival groups. Conclusion: There appeared to be an association between higher carboxyhemoglobin levels and survival in comparison with non-survival patients

Characteristics of patients that experience cardiopulmonary arrest following aortic dissection and aneurysm

Aim: The aim of this study is to investigate the characteristics of patients experience cardiopulmonary arrest (CPA) in the acute phase following aortic dissection and aneurysm (AD). Materials and Methods: Patients who were transported to this department from January 2005 to December 2010 and subsequently diagnosed with AD were included in this study. Patients with asymptomatic AD or those with AD that did not develop CPA were excluded. The AD was classified into four categories: Stanford A (SA), Stanford B (SB), thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA). The frequency of witnessed collapse, gender, average age, past history including hypertension, vascular complications and diabetes mellitus, the initial complaint at the timed of dissection, initial electrocardiogram at scene, classification of CPA and survival ratio were compared among the patient groups. Results: There were 24 cases of SA, 1 case of the SB, 8 cases of ruptured TAA and 9 cases of ruptured AAA. The frequency of males among all subjects was 69%, the average age was 72.3 years old and the frequency of hypertension was 47.6%. There was no ventricular fibrillation (VF) when the patients with AD collapsed. A loss of consciousness was the most common complaint. The outcome of the subjects was poor; however, three patients with SA achieved social rehabilitation. Two out of the three had cardiac tamponade and underwent open heart massage. Conclusion: The current study revealed that mortality of cardiac arrest caused by the AD remains very high, even when return of spontaneous circulation was obtained. VF was rare when the patients with AD collapsed. While some cases with CPA of SA may achieve a favorable outcome following immediate appropriate treatment

A Case of Acute Myocardial Infarction in a Patient Whose Initial Complaints Were Hematemesis and Epigastric Discomfort

The patient was a 64-year-old woman with systemic lupus erythematosus, thrombophlebitis of the lower legs, cerebral infarction with left hemiparesis, and colostomy after perforation of the sigmoid colon. On the morning of her presentation, the patient felt epigastric abnormality. Thereafter, hematemesis occurred twice, leading her to call an ambulance in the afternoon. Upon arrival, electrocardiography before securing a venous route and obtaining blood samples revealed ST segment elevation in leads II, III, and aVF. As her vital signs were stable and her hemoglobin level had decreased by just 1.1 g/dl in comparison to the previous day, emergency coronary angiography (CAG) was performed. CAG revealed complete occlusion at section #4. She underwent right coronary angioplasty with stent placement. The patient’s course after angioplasty was uneventful. On the 15th hospital day, esophagogastroduodenoscopy revealed esophageal erosion and superficial gastritis. She was discharged on foot the following day. When physicians treat patients with hematemesis, electrocardiography and the measurement of troponin are essential before esophagogastroduodenoscopy

The epidemiological findings and characteristic ground glass appearance on chest CT among patients with blunt lung injury

Aim: To clarify the epidemiological findings and characteristics of ground glass lesions on chest computed tomography (CT) after blunt trauma. Setting and Design: A medical college hospital and retrospective study. Materials and Methods: We retrospectively investigated all blunt chest trauma patients who were admitted from January 2004 to December 2010. The inclusion criteria were patients with: (1) chest CT examination on arrival, (2) intrathoracic traumatic lesions confirmed by initial CT, and (3) a second chest CT examination within 7 days from admission. We divided the subjects into two groups. A GG group included subjects who had ground glass lesions on initial chest CT and a control group included subjects who did not have the ground glass appearance. Results: The average age in the GG group was significantly lesser than that in the control group. The ratio of improvement for the value of SpO 2 /FiO 2 between on arrival and the second hospital day and ratio of improvement for CT findings between on arrival and the second CT examination in the GG group was greater than in the control group. Conclusion: The ground glass appearance on chest CT after blunt trauma was not rare, and the patients with ground glass lesions were younger and tended to have a better improvement of oxygenation and CT images in comparison with the patients without these characteristic lesions