Patient: Female, 86Final Diagnosis: PolytraumaSymptoms: ShockMedication: —Clinical Procedure: Resuscitative endovascular balloon occlusion of the aortaSpecialty: Orthopedics and TraumatologyObjective:Unusual or unexpected effect of treatmentBackground:Non-compressible torso hemorrhage continues to be the leading cause of preventable death in trauma patients. Recent case series report that resuscitative endovascular balloon occlusion of the aorta (REBOA) in the trauma population is a technically feasible method to manage the patients with exsanguinating hemorrhage. On the other hand, it seems that REBOA is being widely promoted prematurely. Complications due to REBOA haven’t been reported much in the literature, and they could have been underestimated.Case Report:An 86-year-old female presented to our emergency department following a pedestrian-vehicle accident. On admission, she was hemodynamically unstable with systolic blood pressure (SBP) of 78 mm Hg. She responded to fluid administration, and computed tomography (CT) scan showed cerebral contusion, subarachnoid hemorrhage, pelvic fracture with contrast extravasation, and thoracic spine fracture. Her condition deteriorated after the CT scan, and she became hemodynamically unstable. REBOA was inserted and inflated. Her blood pressure recovered and even became as high as SBP of 180 mm Hg. Transarterial embolization for pelvic fracture was successfully performed. A subsequent head CT scan showed massive intracranial hemorrhage with penetration to the ventricle, which was fatal. She died on the same day due to cerebral herniation.Conclusions:REBOA is now considered as an alternative to resuscitative thoracotomy or even widely indicated to control hemorrhage. We should be more cautious about using REBOA for polytrauma patients since it could make hemorrhage worse. Further research, assessing its potential complications and safety, will be required to elucidate clear indications for REBOA in trauma populations.

AimThis study aimed to clarify the characteristics of patients who presented with severe hypermagnesemia and subsequently underwent emergency hemodialysis.MethodsWe investigated the age, gender, complications, clinical symptoms, causal drugs, electrocardiogram findings, and laboratory data of 15 patients.ResultsMagnesium oxide had been administered in all cases and 14 patients were over 65 years old. The male : female ratio was 6:9. Chief complaints included a disturbance of consciousness, hypotension, bradycardia, and respiratory failure. The median serum magnesium value before hemodialysis was 6.0 (3.7–18.6) mg/dL. The daily dosage of magnesium oxide was ≤ 2.0 g in 12 cases. The median serum creatinine value before hemodialysis was 5.39 (0.54–10.29) mg/dL. However, in two cases, the creatinine value was not elevated. Complications of acute kidney injury exacerbated the hypermagnesemia in nine cases.ConclusionsWe recommend that the serum magnesium value should be measured in older patients who are taking magnesium oxide and are showing signs and symptoms of a disturbance of consciousness, hypotension, bradycardia, and respiratory failure of an uncertain etiology, even if the serum creatinine value is not elevated or the dosage of magnesium oxide is within recommended levels.

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ObjectiveTo examine whether peppy comments from attending physicians increased the workload of residents working in the emergency department (ED).MethodsWe conducted two parallel-group, assessor-blinded, randomized trials at the ED in a tertiary care hospital in western Japan. Twenty-five residents who examined either ambulatory (J(^o^)PAN-1 Trial) or transferred patients (J(^o^)PAN-2 Trial) in the ED on weekdays. Participants were randomly assigned to groups that either received a peppy message such as “Hope you have a quiet day!” (intervention group) or did not (control group) from the attending physicians. Both trials were conducted from June 2014 through March 2015. For each trial, residents rated the number of patients examined during and the busyness and difficulty of their shifts on a 5-point Likert scale.ResultsA total of 169 randomizations (intervention group, 81; control group, 88) were performed for the J(^o^)PAN-1 Trial, and 178 (intervention group, 85; control group, 93) for the J(^o^)PAN-2 Trial. In the J(^o^)PAN-1 trial, no differences were observed in the number of ambulatory patients examined during their shifts (5.5 and 5.7, respectively, p = 0.48), the busyness of their shifts (2.8 vs 2.8; p = 0.58), or the difficulty of their shifts (3.1 vs 3.1, p = 0.94). However, in the J(^o^)PAN-2 trial, although busyness (2.8 vs 2.7; p = 0.40) and difficulty (3.1 vs 3.2; p = 0.75) were similar between groups, the intervention group examined more transferred patients than the control group (4.4 vs 3.9; p = 0.01).ConclusionsPeppy comments from attending physicians had a minimal jinxing effect on the workload of residents working in the ED.Trial RegistrationUniversity Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR), UMIN000017193 and UMIN000017194.

Our study suggests an association of JTAS acuity with overall admission, ICU admission and ED length of stay, thereby demonstrating the predictive validity of JTAS.