Toshibumi Otsuka

Emergency center ultrasonography in the evaluation of hemoperitoneum: a prospective study.

The reliability of ultrasonographic detection (US) of hemoperitoneum in blunt abdominal trauma was evaluated in a prospective study of 72 patients. Independent of the examiner, sensitivity, specificity, and accuracy were, respectively, 86.7%, 100%, and 97.2%. Laparotomy was indicated in 76.9% of US hemoperitoneum-positive cases. No negative laparotomies were performed in this study group. If hemoperitoneum is revealed in US and vital signs are unstable, we think laparotomy is indicated. We believe that US in an emergency center is a quick, safe screening method in the evaluation of blunt abdominal trauma. US might take over a great part of the role of diagnostic peritoneal lavage.

Significance of magnetic resonance imaging in acute head injury.

One hundred seventy-seven patients who had incurred head trauma were studied with magnetic resonance imaging (MRI). Patients varied from those with mild injury without any focal neurological deficit to those with severe injury with post-traumatic coma. Altogether, 177 lesions were demonstrated by MRI in 123 of 177 patients within 3 days of injury using T2-weighted (SE2000/40,2000/111) and T1-weighted (IR1500/500/40) multislice sequences. In contrast, computerized tomography (CT) demonstrated 103 lesions in 90 patients. MRI was superior to CT in the diagnosis of nonhemorrhagic contusions demonstrated as a high-intensity area on T2-weighted imaging. MRI provided some information to evaluate the severity of diffuse axonal injury or to predict delayed traumatic intracerebral hematoma (DTICH).

Blunt traumatic rupture of the heart: an experience in Tokyo

The present study was planned to clarify the characteristics of blunt traumatic cardiac rupture. We performed a retrospective analysis of 63 patients with blunt traumatic cardiac rupture during the period from April 1975 through February 1993. Six of nine patients arrived with recordable blood pressure, and injuries were detected by ultrasonography. Three patients underwent pericardiocentesis before surgery. Seven patients survived overall. The hemodynamics in all seven survivors were stabilized within 3 days after cardiac repair. The survival rate among the patients who arrived with blood pressure was 54%. A patient who fell from higher than 6 meters or a pedestrian hit by car and thrown as short a distance as 6.5 meters may have cardiac rupture. Ultrasonography is a useful, quick, and sensitive way to detect the presence of pericardial fluid. We prefer to do pericardiocentesis with a large-bore catheter under ultrasonographic guidance for continuous pericardial drainage rather than to create a subxyphoid pericardial window for cardiac tamponade.

Clinical value of serial computed tomography with severe head injury

Serial computed tomography (CT) scanning was performed on 138 patients suffering from severe head injuries (i.e., with scores of 8 or less on Glasgow Coma Scale). Standard practice called for scans to be done upon admission (within hours of the injury) and after 1, 3, and 7 days and 1 month. Subsequent CT scans depended on the patients condition. Clinical results at the time of discharge were graded according to the Glasgow Outcome Scale. During the serial CT scan, there were new findings (not visualized on the initial CT scan but appearing on subsequent scans) in 91 of the 138 patients. These new findings were classified into seven types: (1) decreased density collection in the subdural space; (2) ventricular dilatation; (3) intracerebral hematoma; (4) intraventricular hemorrhage; (5) extracerebral hematoma; (6) edema; and (7) infarction. We defined intracerebral hematoma, intraventricular hemorrhage, extracerebral hematoma, edema, and infarction as new lesions. Of the 60 patients with new lesions, 12 had a good outcome and 48 had a poor outcome. Of 78 patients who did not have any new lesions, 60 had a good outcome and 18 had a poor outcome. A significant correlation was found between good outcome and the absence of new lesions and between bad outcome and the development of new lesions (p less than 0.001; X2 = 44.038). We conclude that serial CT scanning can help predict the outcome of patients with severe head injuries and may be very important in their examination and care.

Trimethoprim-sulfamethoxazole for the prevention of methicillin-resistant Staphylococcus aureus pneumonia in severely burned patients

BACKGROUND Patients with severe burns are at increased risk of developing methicillin-resistant Staphylococcus aureus (MRSA) ventilator-associated pneumonia. This study was designed to determine whether MRSA pneumonia can be prevented by prophylactic administration of trimethoprim-sulfamethoxazole (TMP-SMX). METHODS We conducted a prospective, randomized, placebo-controlled study in patients with severe burns (> or = 20%), who required ventilator support. Prophylaxis was done with oral TMP-SMX (80 mg/400 mg) three times daily for 10 days from 4 to 6 days after burn injury. The incidence of MRSA pneumonia and the side effects were evaluated during the administration period. RESULTS Twenty-one patients were assigned to receive TMP-SMX, and 19 patients to receive placebo. The incidence of MRSA pneumonia was 4.8% in the TMP-SMX group and 36.8% in the placebo group, showing a significant difference (p = 0.017). No major side effects of therapy were seen in the TMP-SMX group. CONCLUSION Prophylactic treatment with TMP-SMX can prevent MRSA pneumonia in severely burned patients.

Intracranial Pressure in Head-injured Patients with Various Intracranial Lesions Is Identical throughout the Supratentorial Intracranial Compartment

Subarachnoid pressure was measured by bifrontal catheterization to obtain concurrent comparative intracranial pressures (ICPs). These ICPs were compared in 15 head-injured patients who had differences in the pathological processes affecting the right and left hemispheres. ICPs in these patients ranged from -3 to 130 mm Hg, but no difference was found in the concurrent comparative ICPs. These findings suggest that the supratentorial space can generally be considered as one compartment regardless of the differences in types of intracranial lesions.

Acute traumatic intraventricular hemorrhage in children

Four cases are reported of acute traumatic intraventricular hemorrhage in children revealed by computed tomography (CT). In most cases, the intraventricular hemorrhage had been produced by severe sagittal impact. All of the children were 7 or less on the Glasgow Coma Scale (GCS) on admission. Three had hemorrhage in all ventricles, and one had an intraventricular hemorrhage in the lateral and fourth ventricles. One of them showed enhancement of the blood-filled ventricles, with the appearance of increased ventricular size, on the contrast enhancement CT. Two children with ventricular dilation died soon after injury, although ventricular drainage had been performed; one child remained in a persistent vegetative state, and the other enjoyed good recovery with conservative therapy. Certain features of acute traumatic intraventricular hemorrhage in children are discussed in relation to this series.

Useful ICP Monitoring with Subarachnoid Catheter Method in Severe Head Injuries

ICP in 233 patients with severe head injuries was monitored utilizing a subarachnoid catheter technique. The relationships between initial ICP and GCS, between initial ICP and GOS, between maximal ICP and GCS, and between maximal ICP and GOS were examined statistically. The correlation was significant in each case, but particularly so between maximal ICP and GOS. Thus morbidity and mortality may be dependent upon maximal ICP. Catheterization of the subarachnoid space presents little difficulty using a Tuohy needle for epidural anesthesia as an introducer. Though the catheter is very fine (1.0 mm in outer diameter), failure of waveform occurred in only 2.1% of all patients. The procedure can be easily performed at the bedside, is safe, inexpensive, and useful for the management of severe head injuries. Meningitis was recognized in 4.7% of all patients.

Continuous Monitoring of Jugular Venous Oxygen Saturation in Neurosurgical Intensive Care Units

It is very important for to evaluate cerebral blood flow and cerebral oxygen metabolism of patients who are suffering from severe head injury or severe cerebrovascular disease. It is well known that jugular bulb saturation shows the ratio of cerebral blood flow and cerebral oxygen metabolism. Thus, many trials were carried out to measure jugular bulb saturation to determine cerebral blood flow and cerebral oxygen metabolism. It has been very difficult, however, to measure and record these parameters continuously at bedside. Recent technology now makes it possible to measure and record these parameters at a bedside monitor.

Significance of Magnetic Resonance Imaging (MRI) in Diffuse Axonal Injury

Advantages of magnetic resonance imaging (MRI) to computed tomography (CT) on a diagnosis of diffuse axonal injury (DAI) were discussed. Sixteen patients diagnosed as DAI defined by the criteria of Gennarelli were studied with CT and MRI. Lesions were demonstrated as high intensity areas on MRI of T2 weighted imaging (SE 2000/111) in all of the patients. These lesions were located only in a cerebral white matter in the cases of mild DAI, whereas in the cases of severe DAI located in a basal ganglia, corpus callosum, dorsal part of the brain stem as well as in the cerebral white matter. As for the findings of CT, these parenchymal lesions were not visualized in nine cases including six cases without any pathological findings. Our series suggest that MRI is superior to CT on the diagnosis of DAI and provides some information to evaluate the severity of DAI.