Akitsugu Kohama

An outcome study of out-of-hospital cardiac arrest using the Utstein template—a Japanese experience

Publication of the Utstein style template has made it possible to evaluate and compare national, regional, and hospital based Emergency Medical Services. This research was a national investigation to present outcome data for out-of-hospital cardiac arrest (OHCA) patients in Japan. 3029 OHCA patients who were transported to 10 Emergency and Critical Care Medical Center from November 1997 to April 1999 were recorded according to the Utstein style and the outcome evaluated by logistic regression analysis. Among 3029 OHCA patients, 109 were found dead. The remaining 2920 patients who underwent cardiopulmonary resuscitation (CPR) by emergency medical technicians (EMT) were included in this study. Among these patients, 1294 were considered of primary cardiac origin patients by the EMT and 722 of these patients suffered a witnessed cardiac arrest. Bystander CPR were performed in 28.4% of these witnessed patients and the discharge rate was 3.5% overall and 11.4% in witnessed VF/VT. Outcome analysis showed that a discharge rate in witnessed primary cardiac arrest was 30% in prehospital resuscitation which was 7.5 times higher than in-hospital emergency room resuscitation groups (4.0%). The longer the interval between an emergency telephone call and defibrillation, the lower the 1 month survival rate, which reached almost 0% at 30 min. Follow up evaluation after discharge revealed that the survival rate rapidly decreased from 24 h to 3 months, then became a plateau in primary cardiac patients was rapidly decreased from 24 h to 1 month, then became a near plateau in non-cardiac origin group. To improve the resuscitation rate in the prehospital phase, a prehospital medical control system should be developed with expansion of on scene techniques by Japanese paramedics such as tracheal intubation, administration of emergency drugs and early defibrillation with standing orders. Education and motivation of first responders will be needed and every effort should be concentrated on improving bystander CPR rate.

Coagulation disorders following acute head injury

SummaryCoagulation disorders following acute head injury were investigated in 100 patients: 81 patients survived and 19 patients died. Disseminated intravascular coagulation (DIC) was seen in 24%, and occurred most frequently in acute subdural haematoma, followed by contusional haematoma and contusion. Mortality rate of the patients with DIC was 58%. Level of serum fibrin-fibrinogen degradation product (FDP) was correlated with the amount of damaged tissue. The factors which influenced the prognosis for life were evaluated by multivariate analysis: in 100 patients, activated partial thromboplastin time (APTT) was most closely correlated with the prognosis for life, but in 24 patients with DIC, level of serum fibrinogen was most closely correlated with it.

A New Method for Predicting the Outcome and Survival Period in Paraquat Poisoning

1 To elucidate the importance of lung damage in the prognosis of paraquat poisoning, the respiratory index (RI: A-aDO2/PO2) was analysed in 51 patients with paraquat poisoning. 2 Progressive deterioration of the RI was observed in 43 non-survivors, but not in 8 survivors. In addition, the RI of non-survivors became greater than 1.5 in the course of their poisoning, while that of the survivors remained less than 1.5. 3 The level of the RI (i.e. whether it became greater than 1.5 or not) was found to be a good indicator for the prognosis for life. 4 The RI-time, defined as the time taken from ingestion for the RI to be greater than 1.5, was found to be a good indicator for predicting the survival period in fatal cases. 5 As a result, we conclude that it is important and useful to examine a series of RI and the RI-time in poisoned patients not only to provide proper respiratory care, but also to predict outcome and survival period.

Effects of Hypertonic Saline and Dextran 70 on Cardiac Contractility after Hemorrhagic Shock

OBJECTIVE The effects of a bolus of 7.5% NaCl-6% dextran 70 (HSD) on cardiac contractility were evaluated in anesthetized sheep with hemorrhagic shock. BACKGROUND HSD has been shown to be effective at resuscitation in cases of hypovolemia caused by hemorrhage. Common hemodynamic findings after the injection of HSD in hemorrhagic shock are the restoration of cardiac output, increased blood pressure, and improvement of peripheral circulation. Some mechanisms by which HSD maintains circulation in hemorrhagic shock have been proposed: rapid shift of fluid from intracellular to extracellular space, improved peripheral perfusion, and increased cardiac contractility. Conflicting data exist, however, regarding the positive effect of HSD on cardiac contractility after hemorrhagic shock. METHODS Hemorrhagic shock was induced by shedding mean blood volume of 31.4 mL/kg, and mean blood pressure was maintained at 50 mm Hg for 30 minutes. The HSD group (n = 6) received HSD (4 mL/kg), and the saline group (n = 6) received normal saline (40 mL/kg) after shock. Cardiac functions were measured in both groups using the left ventricular end-systolic pressure-volume relationship and preload recruitable stroke work during the experimental period: before shock, immediately after the resuscitation, and 2 hours after resuscitation. RESULTS Hemodynamic parameters in both groups demonstrated similar changes throughout the experimental period without significant difference between the two groups. Not only the slopes of end-systolic pressure-volume relationship and preload recruitable stroke work but also their placements did not result in any significant differences between the groups. CONCLUSION HSD seems to be an effective resuscitation fluid after hemorrhagic shock because the volume required to maintain circulation is smaller than that of normal saline. Our data, however, show that HSD does not enhance cardiac contractility after hemorrhagic shock.

Occipital Lobe Infarction Caused by Tentorial Herniation

Occipital lobe infarction caused by tentorial herniation was described based on computed tomography findings in nine patients. The whole area of the occipital lobe was involved in five patients; some areas were spared in the others. Infarction other than the ipsilateral occipital lobe was seen in four areas of nine patients: the ispsilateral posterior limb of the internal capsule, contralateral Ammons horn, and two contralateral occipital lobes. Hemorrhagic infarction was seen in two patients.

Application of fibrin glue to burns. Its haemostatic and skin transplant fixation effects in the excised wound.

Fibrin glue was clinically applied to the excised wound in 10 extensively burned patients, and its haemostatic and fixation effects on the isolated skin transplants were investigated. The following advantages resulted from the application of the fibrin glue: The haemostatic procedures and fixation of the isolated skin transplants were simplified. The quick and efficient haemostatic procedures considerably reduced the blood transfusion volume during and after the surgical procedures, by achieving a notable reduction in blood loss. Based on the above merits, the operation time was reduced and, eventually, the surgical stress might be alleviated. Satisfactory haemostatic effects were attained particularly in the limbs without supplemental haemostatic aids, leading us to conclude that the application of fibrin glue to the excised wound in burns is very useful.

Complications associated with barbiturate therapy

Fifty-six patients with elevated intracranial pressure caused by cerebrovascular accident, head injury, etc., were the subjects of this study. They were divided into three groups: low dose barbiturate therapy (15 patients), high dose barbiturate therapy (24 patients), and control group (17 patients). Barbiturate therapy was instituted using thiamylal, and the complications caused by barbiturate therapy were recorded. In the control group, complications occurred in the liver of two patients, but there were no renal or pulmonary complications. Pulmonary, renal, and hepatic complications were common in the barbiturate groups. Complications in the high dose therapy group were significantly more common than in the control group. Opportunistic infections occurred in ten patients, with seven patients having pneumonia. Only one patient, with pneumonia, was seen in the control group. The deaths of three patients were influenced by complications associated with barbiturate therapy, while the single death in the control group was not associated with the complication of barbiturate therapy.

Evaluation of Severity Indexes of Patients with Paraquat Poisoning

1 Three indexes for evaluating the severity of paraquat poisoning based on plasma-paraquat concentration are presently in use; the curves of Proudfood et al. and Scherrmann et al. and the SIPP. Their effectiveness in determining the prognosis of patients with paraquat poisoning was evaluated. 2 To determine which index was more accurate, contingency tables of the three indexes were obtained and compared; Proudfoots curve vs the SIPP Scherrmanns curve vs the SIPP. Proudfoots curve and the SIPP were applied to patients admitted within 24 h after intoxication. Scherrmanns curve and the SIPP were applied to patients admitted more than 24 h after intoxication. The proportions of patients with true positive and true negative results to total patients were compared by a ratio test. 3 Proudfoots curve was found to be more accurate than the SIPP for predicting the prognosis of patients admitted within 24 h (P < 0.05). No significant difference, however, was noted between Scherrmanns curve and the SIPP in determining the prognosis of patients admitted after more than 24 h. 4 In conclusion, Proudfoots curve proved a better index for predicting the outcome of patients who were admitted within 24 h. However, for the prognosis of patients admitted more than 24 h after the ingestion of paraquat, further study is required.

Preoperative Diagnosis of Obturator Hernia by Computed Tomography

A retrospective study of 6 patients with obturator hernia diagnosed before surgery by X-ray and computed tomography (CT) was conducted between 1993 and 2000. The initial CT of the abdomen including the pelvic area revealed incarcerated bowel in the obturator foramen of all 6 patients. All patients underwent laparotomy as soon as possible after CT scans were obtained. Resection of the small bowel was performed in 3 patients, and release of the small bowel was performed in the remaining 3 patients. There were no perioperative deaths. In elderly women who show evidence of small bowel obstruction by abdominal plain x-ray studies, we recommend performing CT scans of the abdomen including the pelvic area for detection of obturator hernia.

Moyamoya-like diseases associated with ventricular hemorrhages: report of three cases.

Three rare cases of moyamoya-like diseases with moyamoya type vessels caused by spontaneous internal carotid artery occlusion, spontaneous middle cerebral artery occlusion, and internal carotid artery occlusion due to cervical irradiation are presented. They resulted in ventricular hemorrhages. One patient died and two survived. Postoperatively, the collateral circulation of the survivors was evaluated by single photon emission tomography using N-isopropyl-[123I]-p-iodoamphetamine. The effectiveness of reconstructive surgery is shown, and moyamoya-like diseases that have been reported are reviewed.