Chiiho Fujii

An analysis of time factors in out-of-hospital cardiac arrest in Osaka Prefecture

OBJECTIVE To ascertain important factors in the improvement of out-of-hospital cardiac arrest survival rates through analysis of data for Osaka Prefecture with the focus on time factors. DESIGN Prospective cohort study according to the Utstein style. SETTING Osaka Prefecture (population 8,830,000) served by a single emergency medical services system. PATIENTS Consecutive prehospital cardiac arrests occurring between May 1998 and April 1999. MAIN OUTCOME MEASURES One-year survival from cardiac arrest, and time factors. RESULT Of the 5047 cases of confirmed cardiac arrests, resuscitation was attempted in 4871 subjects. Of the 982 cases of cardiac origin and witnessed by bystanders, 31 (3.2%) were still alive, and of the 576 cases of non-cardiac origin and witnessed by bystanders, ten (1.7%) were still alive at the 1 year follow-up. The median time from receipt of the emergency call until ambulance arrival was 5 min and that from receipt of the call until the start of cardiopulmonary resuscitation (CPR) was 7 min. For the 214 patients for whom defibrillation was attempted, the median time from receipt of the call until the first shock was 15 min. The median time from receipt of the call until departure of the ambulance from the scene was 16 min and that until arrival of the ambulance at a hospital was 22 min. CONCLUSIONS This study using the standardized format according to the Utstein style clearly elucidates the specific delay of the start of defibrillation by paramedics and also indicates the inappropriate rule for this procedure in Japan.

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.

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.

Preoperative diagnosis of obturator hernia by computed tomography in six patients.

Obturator hernia is a rare condition, and the prognosis of patients with this condition is poor. A retrospective study was performed on six patients with obturator hernia between 1993 and 1998. They had been diagnosed preoperatively by computed tomography (CT). The initial CT scan of the abdomen, including the pelvic area, revealed an incarcerated bowel in the obturator foramen of all six patients. All patients underwent laparotomy on the day of admission. Resection of the small bowel was performed in three patients, and release of the small bowel was performed in the remaining three patients. There were no perioperative deaths. In elderly women who have evidence by abdominal plain X-ray studies of small bowel obstruction, we recommend performing CT scan of the abdomen, including CT scan of the pelvic area, for detection of obturator hernia.

Intravenous detergent poisoning

Case Report: In the literature regarding surfactant poisoning, the route of exposure has almost always been oral. We report a case in which about 40 mL of bath detergent for home use was self-injected. The primary pathophysiologic effects were relative hypovolemia and cardiac dysfunction. The patient experienced frequent ventricular tachycardia, acute renal failure, rhabdomyolysis, hemolysis, and coagulation dysfunction. Intensive care included the administration of antiarrythmial agents and hemodialysis. The patient survived and was discharged from our hospital without sequelae.

Traumatic Intraventricular Haemorrhage

The findings of computerized tomography and clinical features were studied in 19 patients with traumatic intraventricular haemorrhage. Blood was found in various portion of the ventricles. Main sites of the blood was as follows: around the foramen of Monro, 6 patients; in the body and occipital horn of the lateral ventricle, 5 patients; solely in the occipital horn, 8 patients. The haemorrhage around the foramen of Monro, resulting from contusion of the ventral portion of the corpus callosum, septum pellucidum, and fornix, showed an interesting CT finding. Intracranial co-existing lesions were seen in 17 patients, and extracranial lesions were seen in 13 patients, suggesting the external force was excessive. Both the Glasgow coma scale scores on admission and Glasgow outcome scale were generally unfavourable, but 4 patients showed good recovery. The final outcome was mainly influenced by the severity of the co-existing intracranial lesions.

Severe respiratory distress following sodium oleate ingestion.

CASE REPORT Oleic acid and oleate are pulmonary toxins used to create laboratory models of acute respiratory distress syndrome, but there is little information on human toxicity. We report the intentional ingestion of 50 mL sodium oleate 20% by a 22-year-old woman with no symptoms for the first 2 days after ingestion. Her respiratory status deteriorated rapidly on day 3 progressing to acute respiratory distress syndrome (PaO2/FIO2 < 100 mm Hg) on day 4. Treatment with high-dose steroids and intensive respiratory support including high-frequency jet ventilation were associated with gradual but complete recovery by day 39. The delayed onset of symptoms suggested that the lung injury was due to the systemic circulation of oleate to the lungs rather than to direct aspiration. In oral poisoning by sodium oleate, the lung is the first and most lethally affected target organ in humans. This case demonstrates that ingestion of a relatively small amount of sodium oleate can cause delayed, progressively severe, lung injury.

Changes in left ventricular preload and contractility following severe burns in the dog

SummaryTo examine the effects of severe burns on preload and left ventricular (LV) contractility, we continuously measured LV pressures and dimensions in severely burned dogs throughout the early part of the postburn period. Hemodynamic parameters, including cardiac output (CO), mean aortic pressure (MAP), heart rate (HR), LV pressures and their first derivatives (dP/dt), and the LV regional dimension, were measured and compared before and every 30 min after burns were produced (up to 360 min) in four groups: group A (n=7), dogs with sham burns; group B (n=5), dogs with nonresuscitated full-thickness burns involving 50% of the total body surface area; group C (n=6), dogs with burns resuscitated with lactated Ringers solution at 4 ml × kg × % burn/24 h; and group D (n=6), dogs with burns resuscitated with 1.5% dextran in lactated Ringers solution at 2 ml × kg × % burn/24 h. From these measurements, we obtained the LV end-diastolic segment length (EDL) as an index of preload and three indices of cardiac contractility, i.e., peak dP/dt, the percentage of shortening (%ΔL), and mean Vcf. Our results showed that CO, MAP, and preload (i.e., EDL) decreased significantly more in the three burn groups (groups B, C, and D) than in the sham burn group, but that there were no significant differences in CO, MAP, and EDL among the three burn groups. The three indices of contractility also decreased significantly more in the three burn groups than in the sham burn group. When changes in LV end-diastolic pressure (LVEDP) and EDL during the experiment were examined, apparent discrepancies were found in the changes between LVEDP and EDL in the burn-resuscitated groups (C and D); the postburn decreases in LVEDP in the burn-resuscitated groups were significantly smaller than those in the burn-nonresuscitated group, but there were no significant differences in the postburn decreases in EDL among the three burn groups. These findings indicate that: (1) the fall in cardiac output following severe burns was due to both the decreased preload and decreased LV contractility; (2) the decreased preload and LV contractility could not be restored to preburn levels by conventional fluid therapy during the 6-h experimental period; and (3) the possible decrease in LV compliance was more prominent in the burn-resuscitated groups.