To evaluate the emergency medical services (EMS) for out-of-hospital cardiopulmonary arrest (oh-CPA) in Japan, we analyzed 1, 042 oh-CPA cases that had been transported to our hospital between 1989 and 1998 using a multivariate analysis, quantification method II. Prognostic factors influencing the outcomes (spontaneous circulation, survival, and good recovery) of CPA cases were evaluated by the explanatory variates of etiology, age, witnessed arrest, bystander CPR, crew of EMS (medical doctor, emergency life guard (ELG), or ambulance personnel), time interval from collapse to arrival, and arrival status (CPA or out-of-hospital return of spontaneous circulation). In addition, of the 1, 042 oh-CPA cases, we examined the same factors in 211 cardiogenic oh-CPA cases. In the cardiogenic CPA cases, influential factors for survival included arrival status, etiology, time interval and age. Factors for good recovery included arrival status, bystander CPR and etiology. EMS was not an influential factor in any case. However, among the cardiogenic oh-CPA cases, EMS positively influenced both the survival and good recovery. Moreover, Japanese ELGs improved the survival rate of cardiogenic oh-CPA cases. These findings suggest that to improve the outcome of oh-CPA patients, spontaneous circulation should be established in the prehospital setting, the frequency of bystander CPR should be increased, and the time interval from collapse to hospital arrival reduced.

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Hyponatremia following subarachnoid hemorrhage is associated with hypovolemia and is a cause of delayed cerebral vasospasm. The purpose of this study was to investigate whether a sufficient volume of infusion would decrease sodium disorders and delayed cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Twenty-six patients with aneurysmal subarachnoid hemorrhage were operated on within 24 hours after the onset, and positive water balance was maintained using crystalloid and/or colloid solutions for 2 weeks postoperatively. The patients were divided into the spasm group (8 cases) or no-spasm group (18 cases) depending on their cerebral blood velocity, clinical symptoms, and radiological findings. Although the maximal and minimal serum sodium concentrations of the no-spasm group (146±2.4mEq/l, 137±5.3mEq/l, respectively) remained within normal ranges, those of the spasm group (150±8.7mEq/l, 132±10.3mEq/l, respectively) fluctuated widely. The increase in the serum sodium concentration in the spasm group was frequently associated with excretion of hypotonic urine and loss of free water. Furthermore, the onset of vasospasm followed the decrease in serum sodium concentration in the spasm group. The perfusion volumes assessed by central venous pressure and the concentrations of serum total protein were comparable between the groups. We concluded that the delayed cerebral vasospasm could not be prevented in those patients whose serum sodium concentrations widely fluctuated even though hypovolemia was avoided. Since the cause of the increase in the serum sodium concentration is the excretion of the hypotonic urine in the early phase of subarachnoid hemorrhage, control of the urine osmolarity and the serum sodium concentration is important in preventing delayed cerebral vasospasm following aneurysmal subarachnoid hemorrhage.

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We report a case of a ruptured pulmonary arteriovenous fistula (PAVF) which caused shock. A 72-year-old woman was transferred from a local hospital to our hospital because of sudden onset of left chest pain that followed hypotension and left pleural effusion. A suspended rupture of an aortic aneurysm was suggested, but results of transesophageal echocardiography and enhanced computed tomography provided no evidence of this diagnosis. Also, aortography performed on the 2nd hospital day, revealed no abnormalities of the intercostal and bronchial arteries, nor the source of the hemothorax. On the 3rd hospital day, she developed shock due to recurrent bleeding, therefore, probe thoracotomy was performed. Pulsative bleeding from the lung surface of the left S⁸ segment was observed and a diagnosis of a ruptured PAVF was confirmed. Left lower lobectomy was carried out and she was discharged on the 26th hospital day. There are few reports describing the intrapleural rupture of PAVF. This case suggests that pulmonary arteriography should be considered in addition to aortography in patients with sudden onset of chest pain and hemothorax.

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We report a case of gastric rupture caused by cardiopulmonary resuscitation (CPR). The patient was a 60-year-old man who had undergone cardiopulmonary arrest (CPA) soon after an arrhythmic event at his office. A bystander had performed CPR for the patient until the paramedic crew arrived. The crew then performed electrical defibrillation, which resulted in the recovery of the patient's spontaneous circulation, at which time he was admitted to the critical care unit of our hospital. On admission, abdominal CT and radiographic examinations revealed a large volume of free air in his abdominal cavity. The case was diagnosed as gastro-intestinal rupture caused by CPR. Emergency suturing of the gastric lining was carried out following initial coronary angiography. The patient survived this surgical intervention and was subsequently discharged without disabilities. This is a rare case of gastric rupture as a complication of CPR, which to date, has been documented in only 8 cases including ours in the Japanese literature. Gastric rupture as a complication of CPR has never been reported as the direct cause of death among the deceased cases. Nonetheless, our report as well as those of the past underscore the importance of correctly administering CPR so as to avoid complications such as gastric rupture.

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