近年,救命救急医療の発展に伴い,救急隊には的確な観察と適正な搬送が要求されている。欧米では外傷に関し種々のプレホスピタル・スコアが検討されているが,本邦ではほとんど検討されておらず,またシステムの異なる欧米のものを一概に適用するわけにもいかない。われわれは1994年,本邦で1972年に報告された外傷指数(Japan Trauma Index; JTI)をもとに新たな外傷トリアージスコア(Trauma Triage Score; TTS)を考案した。今回,外傷患者の重症度評価に対するTTSの有用性を検討するため,客観的重症度としてInjury Severity Score (ISS)を用い,それらの相関を検証した。対象と方法:当地域3市における全外傷患者に対し,1997年3, 6, 9, 12月(計1466件)の期間,現場で救急隊にTTSをつけてもらった。3週間後に全搬送先に郵送調査で確定診断名を記入してもらい,ISSを算出した。TTSに関しては,緊急手術・集中治療を要する患者,多発外傷や瀕死の患者を重症とし,ISSに関しては16点以上を重症としたうえで,TTSの重症予測正診率を感受性・特異性などを用いて検討した。またTTSとISSとの関係を単回帰分析により検証した。さらに全体の相関だけではなく,市ごとにも検証した。結果:TTSの重症予測正診率はsensitivity 93%, specificity 96%であった。また決定係数(r²)は0.59であった。しかし市ごとにみると相関は異なっていた(0.64, 0.62, 0.45)。考察:われわれが考案したTTSは救急隊が実際に現場で使用でき,かつ個々の外傷患者の重症度を的確に表すものであった。

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目的:1997年4月より,「低侵襲治療」という観点から,GDCによる塞栓術を治療の第1選択として急性期破裂脳動脈瘤症例の治療を行ってきた。本論文の目的は,自験例をもとに脳動脈瘤塞栓術の治療成績問題点などを検討することである。方法:塞栓術の適応条件は,(1)動脈瘤のサイズが2mm以上のもの,(2) DSA上で動脈瘤のneckと周囲血管がある程度分離できるもの,(3)大きな脳内血腫を伴わないものである。2000年3月までの3年間に塞栓術を施行した急性期破裂脳動脈瘤症例105例を対象とした。結果:(1)水頭症を伴わないH & K grade Vの予後は不良であり,grade Vの症例は意識レベルの改善を待って治療すべきである。(2)高齢者でもgradeのよい症例では急性期塞栓術の治療結果は良好である。(3)術中出血は,カテーテルまたはガイドワイヤーによる動脈瘤貫通によるものが3例,coilingに伴うものが3例であった。(4)術中血管閉塞は4例で,中大脳動脈瘤が2例,カテーテルからの血栓が2例であった。(5)再出血は5例で,loose packingによるもの2例,coil compactionに伴うもの2例,IC superior wallの動脈瘤1例であった。(6)症候性血管攣縮の発生率は6例5.7%で低率であった。(7) coil compactionは7例にみられ,動脈瘤の長径が6～7mm以上のものに多く,このうち2例に再出血が生じた。結論:(1)術中出血,血管閉塞などの術中合併症やcoilのloose packingによる再出血は,適応症例を選び手技に習熟することで,ある程度回避可能である。(2)今後の課題は,coil compactionや動脈瘤再増大を予防するために,動脈瘤内をより血栓化器質化できる方法を開発し,塞栓術の確実性をさらに高めることである。

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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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