Background Peripheral varicose veins are common condition. A rupture of an imperceptible varicose vein can cause a fatal hemorrhage. Patients should be informed that surgery can aggravate varicose veins and cause them to rupture in the lower extremities, which are prone to varicose vein formation. Case presentation: An 86-year-old male patient underwent open repair and fixation of a left ankle joint fracture 10 years prior to presentation. He had no specific symptoms; however, he suddenly began bleeding profusely from his left lower extremity during work and was rushed to the emergency room. He was in shock during transport; therefore, he was administered fluids and pressure hemostasis before arriving at the hospital. A 5 mm ulcer was observed in the left ankle joint, which was urgently removed after high-level ligation, including the varicose vein, and his circulation stabilized. The postoperative course was uneventful, the ulcer closed, and the patient was discharged on the second day. The histopathological examination revealed a suture in the outflow tract from the varicose vein that may have been caused by surgery to the previous left ankle joint fracture, and an organizing thrombus may have formed as a result. Conclusions We experienced a case of shock due to a varicose vein rupture with an unidentifiable bleeding point on site. This case highlights the necessity to inform patients with vein ligation about the possibility of varicose vein formation in the periphery and brings awareness to emergency staff who handle bleeding cases that a ruptured peripheral varicose vein could be the cause.

Background Humeral intraosseous infusion (IOI) is often performed in the prehospital setting by rapid response vehicle staff. IOI is used to administer extracellular fluid products and resuscitation drugs such as adrenaline to patients with trauma and cardiac arrest when venous channels are difficult to secure. However, in Japan, its usefulness is not well recognised, and it is rarely performed aggressively. This study aimed to demonstrate that humeral IOI is superior to the conventional peripheral venous infusion (VI) in cardiac arrest.Methods Among cases that received emergency care by rapid response vehicle staff from 2017 to 2022, 363 patients with cardiac arrest were transported to our institution with well-defined timing information. Patients were divided into humeral IOI and peripheral VI groups and compared in terms of age, sex, time from dispatch to contact and arrival at the hospital, time spent at the scene, distance travelled, type of injury, and return of spontaneous circulation (ROSC). Incident reports related to IOI during this period were also investigated. Continuous variables were compared by analyses of variance. Categorical data were compared using the chi-square test.Results There were no significant differences in terms of age, sex, time (min) from onset to dispatch (IOI: 3.19 ± 0.88, VI: 3.85 ± 0.60, P = 0.54), contact (IOI: 13.53 ± 0.96, VI: 14.11 ± 0.66, P = 0.62), and hospital arrival (IOI: 30.37 ± 1.15, VI: 30.51 ± 0.79, P = 0.92), time spent at the scene (IOI: 8.96 ± 0.35, VI: 8.25 ± 0.24, P = 0.1), or mileage (km) (IOI: 9.23 ± 0.46, VI: 9.58 ± 0.32, P = 0.53). There were significantly more cases of ROSC in the IOI group than in the VI group (IOI: yes 47: no 70, VI: yes 41: no 95, P = 0.001). There were no incident reports, such as unnoticed complications, continued infusions, and needle stick injury.Conclusions Humeral IOI required the same amount of time to perform as conventional peripheral VI but showed better outcomes in terms of ROSC. Humeral IOI is a valid infusion route until the completion of primary care. This simple and reliable procedure should be feasible for future prehospital emergency care.

Background Pasteurella multocida-related sepsis can cause purpura fulminans (PF), a rare thrombotic disorder that often presents acutely and is potentially fatal. As a consequence of disseminated intravascular coagulation, this hematological emergency originates from micro-thrombotic occlusion of peripheral blood vessels and resulting circulatory failure. Thus far, no studies have reported the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for saving lives in patients with worsening respiratory and circulatory failure. Moreover, the development of non-occlusive mesenteric ischemia after VA-ECMO has not yet been documented. Here, we describe the case of a 52-year-old female patient with PF and non-occlusive mesenteric ischemia due to Pasteurella multocida-related sepsis who received VA-ECMO. Case presentation A 52-year-old-female patient presented to the hospital with a week-long fever and worsening cough. Chest radiography findings revealed ground-glass opacity. We made a diagnosis of acute respiratory distress syndrome due to sepsis and initiated ventilatory management. Because respiratory and circulatory parameters were not maintained, VA-ECMO was introduced. After admission, ischemic findings were observed in the periphery of the extremities, and a diagnosis of PF was made. Pasteurella multocida was detected in blood cultures. On day 9, the sepsis was cured with antimicrobial treatment. The patient’s respiratory and circulatory status improved, and she was weaned off VA-ECMO. However, on day 16, her stable circulatory system collapsed again, and her abdominal pain worsened. We performed exploratory laparotomy and noted necrosis and perforation of the small intestine. As a result, partial resection of the small intestine was performed. Conclusion In this case, VA-ECMO was used to maintain circulatory dynamics during septic shock in a patient with Pasteurella multocida infection who developed PF. Surgery was also performed for complicated ischemic necrosis of the intestinal tract, helping save the patient's life. This development illustrated the importance of paying attention to intestinal ischemia during intensive care.