In recent emergency medicine development in Japan, emergency personnel must properly assess ill or injured patients and transport “the right patients to the right hospital at the right time.” In the evaluation of trauma victims in the prehospital setting, many methods have been researched in the West. In Japan, however, few studies have focused on prehospital assessment. Scores from overseas should not be applied indiscriminately because prehospital and medical backgrounds differ. In 1994, we devised a new Trauma Triage Score (TTS) based on the Japan Trauma Index (JTI) published in 1972. We studied the correlation between TTS and severity in trauma victims by using the Injury Severity Score (ISS) as outcome. Materials and Methods: Emergency personnel prospectively completed TTS at the scene for all trauma patients (1, 466 cases) in 3 cities in 4 nonconsecutive months in 1997. Three weeks later, we sent questionnaires individually to each accommodating institution to obtain a definitive diagnosis for calculating the ISS. In our TTS, severe trauma was defined as any patient who seemed to need emergency surgery, to require direct admission to the intensive care unit, or to have multiple trauma. In the ISS, any patient with a total score of 16 or greater was classified as severe trauma. Our TTS was evaluated using the following criteria: predictive values for triaging severe trauma using standard epidemiologic criteria with a 4-fold table; and correlation between TTS and ISS using simple regression analysis. Additionally, the correlation was judged in each city individually. Results: TTS appeared to perform triage with a sensitivity of 93% and a specificity of 96%. The coefficient of determination (r²) was 0.59, but differed in each city (0.64, 0.62, 0.45). Discussion: TTS is both a practical score that emergency personnel can use in the field, and an effective score that predicts severity of each trauma patient accurately.

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Objective: Since endovascular embolization with Guglielmi Detachable Coils (GDC) was introduced in April 1997, we have used this as the treatment of first choice in treating acute ruptured cerebral aneurysm based on our definition of candidates for this treatment modality. We retrospectively analyzed our patient series and discuss problems with this therapy. Methods: Candidates defined for GDC embolization had (1) an aneurysm at least 2.0mm or more in size, (2) the aneurysm neck easily distinguished from surrounding vessels on digital subtraction angiography (DSA), and (3) no massive hemorrhage in computed tomography (CT). Subjects numbered 105 treated in the 3-year period ending in May 2000. Results: The outcome of Hunt & Kosnic grade V aneurysm without hydrocephalus was poor, suggesting that such patients be treated after their consciousness level had improved. The outcome of elderly patients with a better grade were favorable even when they underwent embolization in the acute stage. Intraoperative bleeding occurred in 3 when the aneurysm was pierced with a catheter or guidewire and by coils in 3. Intraoperative vascular occlusion occurred in 2 with middle cerebral aneurysm and catheter-related thrombosis in 2. Rebleeding occurred in 5 due to loose packing in 2, coil compaction in 2, and an IC-dorsal aneurysm in 1. Symptomatic vasospasm occurred in 5.7% (6 of 105). Coil compaction was noted in 7 in which the long diameter of the aneurysm tended to be 7mm or more, 2 of which rebled. Conclusion: Intraoperative complications such as bleeding, vascular occlusion, and rebleeding due to loose coil packing may be avoided by selecting optimal candidates and employing skilled technique. Among issues remaining is increasing the embolization accuracy by developing better thromoblization and aneurysm organization to prevent coil compaction and aneurysm regrowth.

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We treated a rare case of necrotizing fasciitis due to Photobacterium damsela (P. damsela) infection, a halophilic gram negative bacillus. A 76-year-old man suffered a minor puncture wound to his right index finger from the fin of a sea bass. He observed no bleeding and paid no attention to the puncture. Some 27 hours later, he noted pain and swelling of his right palm. He went to a local emergency clinic and received antibiotics for a diagnosis of cellulitis. Despite antibiotic therapy, inflammation spread to his forearm. He revisited the clinic and was admitted 32 hours after the puncture wound. By this time, severe pain, swelling, and erythema had spread to his shoulder. He was sent to our emergency center about 36 hours later. Upon arrival, he had gone into shock. We made a diagnosis of necrotizing fasciitis and conducted surgical debridement, but found necrotic tissue in the pectoral muscle, necessitating right thoracoscapular dissection. After surgery, he was treated in the intensive care unit (ICU), but did not come out of shock and died 2 days after admission of multiple organ failure. P. damsela was isolated from necrotic tissue.

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Acute vertebrobasilar arterial occlusion results in severe neurological deficit or death. Since the outcome of such occlusion patients is poor, recanalization is often required; but may result in severe neurological complications. To clarify variables affecting recanalization and outcome in occlusion patients, we retrospectively analyzed the clinical and radiographical outcome in 5 such patients treated endovascularly by thrombolysis using urokinase (UK). We found that recanalization markedly reduced neurological deficit and that early recanalization was extremely effective. Since hemorrhagic complications were severe, we suggest that the amount of UK used be limited to less than 500, 000 IU.

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We report a 4-year-old girl with a compound depressed skull fracture compressing the superior sagittal sinus. The patient fell from a second storey at home. Computed tomography (CT) showed a compound depressed skull fracture overlying the superior sagittal sinus without hemorrhagic lesions. Angiography showed abnormal blood flow in the left frontal cortical veins and an interrupted superior sagittal sinus. Conservative treatment is generally acceptable for a compound depressed skull fracture overlying a major venous sinus. We hold that surgery in acute phase to reduce the risk of infection and delayed intracranial hypertension is indicated if the patient is conscious.

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A case of Kusanon A^® poisoning complicated by Heinz body hemolytic anemia is reported. A 67-year-old woman ingested Kusanon A^® (100ml) while attempting suicide and was admitted 2 hours later. Serum 3, 4-dichloroaniline concentration was higher 48 hours after admission, followed by methemoglobinemia peaking (24.2%) 60 hours after admission in spite of normal serum methemoglobin on admission. Although methemoglobinemia improved without administration of methylene blue, hemoglobin fell to 12.2g/dl with bite cells and erythrocytes containing Heinz bodies on hospital day 6. After the disappearance of Heinz bodies on hospital day 17, hemolytic anemia gradually improved with a high reticulocyte count and she was discharged on hospital day 40. Kusanon A^® poisoning causes symptoms such as conscious disturbance, metabolic acidosis, and methemoglobinemia. Although several authors reporting Kusanon A^® poisoning focused on delayed methemoglobinemia, hemolytic anemia has not been referred in detail. Our experience reveals the importance of hematological ex-amination to help determine hemolytic anemia in advance.

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A 15-year-old boy with a neck injury transferred to our emergency room was alert and cooperative. During surgical closure of the wound, he vomited and became somnolent. A piece of brain tissue was found in vomit. Computed tomography (CT) showed pneumocephalus and a small hemorrhage in the left frontal lobe. Surgery undertaken found an irregular bone defect in the plamun sphenoidale and a dural laceration in the frontal base. The dura of the left frontal convexity was also lacerated. These findings suggested that an unknown foreign body penetrated the right lateral neck and the skull base through the nasopharynx, then reached up to the frontal bone. Postoperative course was uneventful. He witnessed later that he hit his neck on to an iron rod protruding from concrete blocks when he fell. He had known that this rod had penetrated his neck. Orbitocranial stab wounds may associate penetrating brain injuries, but it seems quite rare that a cervical stab wound complicated a penetrating brain injury. It should be stressed that physicians and paramedics must glean information about the modality of penetrating injuries.

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