Kikushi Katsurada

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.

To-and-Fro Movement and External Escape of Carotid Arterial Blood in Brain Death Cases. A Doppler Ultrasonic Study

In brain death cases who showed nonfilling phenomena in the internal carotid angiograms, the blood flow velocity patterns of the common carotid arteries were characterized by involvement of a single systolic peak and a marked reverse flow component which had never been observed in healthy subjects. The individuality of each blood flow velocity pattern in the common, internal and external carotid arteries was made clear by placing the transducer in contact with the respective artery in a certain case. The Doppler signal from the internal carotid artery involving a signal from a reverse flow was slightly detectable, even if the blood pressure was elevated by norepinephrine infusion and the external carotid artery was temporarily compressed. The blood flow velocity pattern of the external carotid artery was similar to the pattern of the common carotid artery. The peculiar flow pattern indicates that a brain death case has a to-and-fro movement in the internal carotid blood flow and an external carotid escape of common carotid arterial blood.

Laterality of air volume in the lungs long after blunt chest trauma.

To clarify a cause of the persistent decrease in lung capacity seen several years after blunt chest trauma, 17 patients with blunt chest trauma (10 with unilateral lung contusion, 7 with bilateral lung contusions; 11 of these with unilateral flail chest) inflicted 1 to 6 years previously and 10 normal volunteers (control) were studied. Lung air volumes (AV) were measured by spirometry (AVsp) and by computed tomographic (CT) scan (AVCT = AVCT.Rt+AVCT.Lt) under the same conditions. Hemithoracic spaces were also calculated by CT scan. The average AVsp in patients (76% +/- 8%) was lower than in the controls (98% +/- 5%). AVCT was consistent with AVsp in all the measurements. %AVCT.Rt and %AVCT.Lt, which were adjusted by the ratio of AVCT.Rt to AVCT.Lt in the controls, decreased significantly in unilateral contused lungs (71% +/- 8%). Fifty-eight percent of contused lungs showed small fibrous changes on the CT scans. The ratio of the hemithoracic space on the flail chest side to the opposite side was 0.95 +/- 0.05. These results suggest that the persistent decrease in AV long after blunt chest trauma might be caused by a constriction of contused lung resulting from fibrous changes.

The emergency medical system in Japan.

Abstract In Japan, ambulance service was originated by the Osaka Branch Office of the Japan Red Cross in 1931. In 1933 the fire department organ of Yokohama started ambulance service. It was, however, without any legal requirements. Since the early 1960s, Japan has experienced a rapid development of industry and economy, so that traffic accidents have increased, necessitating a nationwide ambulance service system. In October 1961 the Director-General of the Fire Defense Agency organized the Fire Defense Council to study the problem of ambulance service. In response, the Fire Defense Act was ammended in 1963, assigning ambulance service responsibilities to Fire Defense organs. During 1982 total ambulance runs numbered 2,125,447, and the total number of transported persons was 2,049,487. Response time is excellent in Japan. More than 50% of persons who called an ambulance could get help within five minutes. First-aid management was given to 56% of total transported persons. Of these, temperature regulation was most often administered, followed by oxygen inhalation, dressing, and hemostasis. Currently, 2,965 (91.1%) municipalities provide ambulance services to 98.3% of the population. The Japanese emergency medical system has serious problems, however, such as an inadequate number of general hospitals and a flood of nonemergent patients. To alleviate such problems, the Ministry of Health and Welfare developed the critical emergency transfer system in 1977.

Haemodynamic defect in patients with severe head injury.

Haemodynamic studies were made in 34 patients with severe head injury. The changes of cardiac output were noteworthy and correlated well with the clinical course and the prognosis of the patients. Marked systemic hypotension at the moment of brain death was mainly caused by the decrease of cardiac output. At this moment, peripheral resistance fell only to normal limits from the raised level. In the patients who survived, the cardiac output increased in proportion to the respiratory insufficiency, that is, the increased A-aDO2 and Qs/Qt. The increase of oxygen consumption was also accompanied by an increased cardiac output, but in the patients with the severest head injury who died, the cardiac output remained low. It failed to respond to increased A-aDO2 and Qs/Qt, and oxygen consumption remained low.

Pulmonary edema in acute carbon monoxide poisoning

SummaryThe chest radiograms and the arterial

Study of Prognostic Index for Patients with Severe Head Injury

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Hyperoxia of internal jugular venous blood in brain death

values were studied in 61 patients suffering from severe acute CO poisoning. 22 patients (36.1%) showed abnormalities on chest film taken at the time of admission. The radiologic pulmonary abnormalities were classified into three patterns: 1. ground glass density, 2. interstitial edema, and 3. intraalveolar edema.Particular emphasis was placed on the diffuse, homogenous and hazy density like ground glass on chest films, as the patients who presented “ground glass density” showed marked hypoxemia at the time of admission. Clinical symptoms of pulmonary edema were manifested in 4 eases (6.6%) in this series of patients.Pulmonary edema in acute CO poisoning is far commonner than previously considered, and possible mechanism to develop it was discussed.