For patients with aneurysmal subarachnoid hemorrhage (SAH) require prompt diagnosis. To determine factorsdistinguishing those with SAH from those with nonhemorrhagic headache and to identify those requiring computed tomography (CT) of the brain, we reviewed 113 patients with acute headache brought to our emergencycenter by ambulance. Diagnosis was made using CT or lumbar puncture. Those who had consciousness disturbance or traumatic episodes on arrival were excluded. We divided patients into 2 groups--SAH (n=30) vs controls (n=83)--and analyzed vital signs and symptoms using univariate analysis. Higher white blood cell count (>8000/mm³), lower body temperature (<36.0°C), nuchal rigidity, nausea, convulsion, and higher systolic blood pressure (>160mmHg) were clearly associated with SAH. All those with SAH had at least 1 of the 6 factors, resulting in a sensitivity of 100% and a specificity of 18.1%. Our results suggest that patients with 1 or more of the 6 factors should undergo head CT for SAH diagnosis, even if they do not present typical severe headache.

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Electrocardiography in out-of-hospital cardiopulmonary arrest was recorded at the emergency scene from 1993 to 1999 in Nagaoka City, which encompasses 320km² with a population of 202000. Of 871 consecutive cardiopulmonary arrests, electrocardiography was recorded in 797 cases (91.5%) at the emergency scene; 599 cases were classified as intrinsic disorder and the remainder extrinsic disorder. Electrocardiography in the intrinsic disorder showed ventricular fibrillation in 57 (9.5%), electromechanical dissociation in 124 (20.7%), and cardiac standstill in 418 (69.8%). The extrinsic disorder group showed ventricular fibrillation in 3 (1.5%), electromechanical dissociation in 45 (22.7%), and cardiac standstill in 150 (75.8%). Cardiopulmonary resuscitation was initiated by a bystander in 16.4% of intrinsic disorders and 22.2% of extrinsic disoreder. Ventricular fibrillation was therefore relatively rare in the overall population of out-of-hospital cardiopulmonary arrests in Japan. To save more of those undergoing out-of-hospital cardiopulmonary arrest, resuscitation using drugs by emergency life-saving technicians may be necessary at the emergency scene.

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Distigmine bromide is commonly or occasionally prescribed to treat urinary bladder dyskinesia caused or induced by side effects of psychiatric medication such as antidepressants. We report sudden cardiovascular collapse caused by cholinergic crisis due to distigmine bromide intoxication in a patient with shizophrenia who attempted sucide by antipsychiatric drug overdose. Because the patient did not recognize distigmine bromide as a psychiatric medication, he ingested it with other drugs and was transferred to our department. We did not initially noticed the cholinergic crisis and treated him with the ordinal method against phenothiazine poisoning. He went into sudden cardiac arrest about 90min after admission. After cardiopulmonary resuscitation (CPR), hemodialysis was conducted and atropine sulfate administered. The ingested dose of distigmine bromide was assumed to be 175mg, indicating about 23% LD50 in mice. He fully recovered without complications on hospital day 6. Such a case of unnoticed cholinergic crisis due to distigmine bromide overdose is rare. We include a review of the literature.

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We treated a case of metabolic acidosis and delirium induced by 4g of nalidixic acid ingestion. A 32-year-old previously healthy woman suffering from dyspnea was brought to our emergency treatment center delirious, screaming continuously, and hyperventilating. Arterial blood gas analysis revealed acidemia with metabolic acidosis and compensatory respiratory alkalosis. Intravenous administration of sodium bicarbonate, gastric lavage, and activated charcoal administration through a gastric tube restored her orientation after receiving sodium bicarbonate, which suggested acidemia affected her consciousness. She was lucid and had fully recovered 12 hours after drug ingestion. One hour after drug ingestion, serum nalidixic acid concentration was 155.16μg/ml, 68.80μglml 3 hours after, and 0.065μg/ml 14 hours after.

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Aortic valve injury with atrial alve injury with atrial septal rupture confirmed by transesophageal echocardiogram. The patient was treated successfully with a prosthetic valve replacement and direct suture of septal defect on postinjury day 5. The postoperative course was uneventful except. The decision to undertake surgical treatment should be made carefully in each case with special consideration to cardiac decompensation and the risk of heparinization.

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Adequate immune function must be maintained to protect the host from infection. While excessive inflammatory response may destroy normal tissues, antiinflammatory reaction and subsequent immunosuppression may also result in severe infection. It has recently been shown that the lower expression of human leukocyte antigen (HLA)-DR on monocytes correlates with the higher incidence of sepsis, and that interferon-gamma (IFN-γ) administration is effectively restores monocyte HLA-DR expression. We attempted IFN-γ treatment in a septic patient under monocyte HLA-DR expression monitoring. A 62-year-old man undergoing ventriculoperitoneal shunt surgery after subarachnoid hemorrhage suffered from shunt-tube infection and peritonitis. After undergoing celiotomy, he developed severe pneumonia refractory to antibiotic treatment to which the pathogen was sensitive in vitro. Low HLA-DR expression on monocytes, 47.2%, was determined and IFN-γ 1a therapy of 2.5×10⁵JRU (Japanese reference unit)/day, div, for 7 days was begun. HLA-DR expression rose rapidly to 73.5% after 5 days and to 88.5% by 4 weeks. The patient recovered fully from pneumonia, and the PaO₂/FIO₂ ratio and APACHE II score improved in parallel with the restoration of monocyte HLA-DR expression. Monocyte HLA-DR expression measurement appears to be a reliable marker of immune function. IFN-γ treatment may thus become useful adjuvant therapy in immunologically compromised patients.

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In 2 cases of shaken-baby syndrome, 5-and 2-month-old boys were admitted to the Emergency Center of Nara Medical University Hospital due to seizure and unconsciousness. Head computed tomography (CT) scans revealed subdural hematoma. Neither child had a history of trauma, but both had been shaken by a family member. Many studies report that patients with shaken-baby syndrome have a history of child abuse, but the boys in this report had no history or sign of abuse. It appears that the mechanism of their injury was the shaking seen in routine play with children under 1 year of age, but the impact was hard enough to form a subdural hematoma. It is difficult to take an accurate medical history of patients with shaken-baby syndrome because most have been seen in abused children, and also because family members do not imagine that routine play such as dandling their children could cause this rare head trauma. Physical examination revealed no sign of trauma, so the diagnosis of this syndrome could be delayed. Since many patients with this syndrome have poor prognosis, physicians in the emergency room (ER) should be aware of this rare syndrome.

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