Much previous research agrees that inflammatory mediators and cytokines play an important role in acute pancreatitis progression. Acute pancreatitis is a common internal disease causing systemic inflammatory response syndrome (SIRS) induced by hypercytokinemia. In Japan, blood purification therapy is recognized a special treatment for severe acute pancreatitis (SAP). The new Japanese severity score for SAP proposed in 1998 included the presence of 3 or more of clinical conditions of SIRS as a prognostic factor. To investigate efficacy of our treatment adding continuous hemodiafiltration (CHDF) to SAP and to evaluate the new severity score for SAP, we studied 16 consecutive patients diagnosed with SAP at critical care emergency center. Severity scores on admission and 5 days after admission were compared to duration of ICU stay by the Spearman rank correlation coefficient. Relationships between scoring parameters divided into 2 groups by mean value and duration of ICU stay were assessed by the log rank test. Relationships between categoric factors were analyzed by the Chi-square test. CHDF was introduced to 10 patients. Survival was 93.8% in all patients, and 90.0% in CHDF patients. Both severity scores on admission and 5 days after admission were significantly related with duration of ICU stay. Among parameters, the presence of clinical symptoms and a decrease in base excess correlated significantly with prolonged duration of ICU stay. We found that CHDF is useful in SAP treatment. The severity score is useful in evaluating SAP severity on admission, and is helpful in early appropriate treatment based on the patient's clinical condition. Both the presence of clinical symptoms and decreased base excess on admission are important parameters for the clinical course after admission. This score may also be a beneficial predictor in the course of treatment.

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A retrospective analysis of nine patients with multiple spinal injuries is presented. Patient ages at admission ranged from 17 to 50 years (mean 26.4 years) and the male:female ratio was 7:2. Cause of injury was a motor vehicle accident in six patients, and a fall in three patients. Neurological examination of the nine patients on admission showed complete motor and sensory loss (Frankel A) in 3 patients and incomplete neurological deficits in 6 patients (Frankel B: 1, C: 3, E: 2). Six (67%) of the nine patients had associated injuries. The additional injuries included head injury in two patients, chest injury in four patients, abdominal injury in one patient, fracture of the extremities in two patients and pelvic fracture in one patient. All patients had cervical spinal injuries. Eight patients had injury in at least two spinal regions (upper cervical and lower cervical spinal injuries in one patient, upper cervical and thoracic spinal injuries in one patient, middle∼lower cervical and thoracic spinal injury in six patients and middle∼lower cervical and lumber spinal injuries in one patient). One patient had cervical spinal injuries in two sites and a thoracic spinal injury. Our results indicate that examination of the whole spine should be performed in a patient with spine and spinal cord injuries accompanied by other organ injuries.

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Objective: To clarify emergency responses and examine better emergency systems for patients under have home therapy. Setting: Emergencyn and critical care center of Kyorin University Hospital. Patients: Nineteen patients receiving home therapy. Methods: We investigated differences in age, communication with and the responses of patients to their home doctor, the person who called the emergency services, time of patient arrival, onset pattern, diagnosis by home doctor, activities of daily living when transported to our hospital, reason why the ambulance dispatcher chose our hospital, diagnosis in our hospital, and outcome, for each patient. Result: The average age of the patients was 79.4 years old. In 7 cases they called their home doctors and in 3 of these the doctor immediately went to the patient, while the doctor called an ambulance in 3 cases. In only 1 case was it unknown what the doctor did. Calls were most frequently made by the family of the patients, and they usually called at night. There were 12 cases of sudden onset and 7 cases of gradual onset. Most patients had home therapy for chronic respiratory and neurological diseases and 10 patients needed full support. The details of the at-home medical treatment were unknown except for 9 cases whoh had oxygen therapy from the ambulance crew on admission. The most common reason why the ambulance dispatcherchose our hospital was loss of consciousness, the second was dyspnea, the third was shock status, and the fourth reason was cardiopulmonary arrest (CPA). The most common diagnosis in our hospital was respiratory disease. Eleven of 15 cases without CPA were eventually discharged. Discussion: To provide good emergency response for home therapy patients, we must educate emergency system and the critical emergency medicine. There must be a good network between the home therapy staff and emergency medicine staff, including the ambulance crew, to make a good overall emergency medical system.

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Objective: We evaluated the usefulness of brain metabolism in neurointensive care. We measure cerebral cortical cellular pH (pHi) using an intracranial tonometer applying the principle of measuring gastric mucosal pH and evaluated the relationship between pH and CPP, jugular bulb oxygen saturation and prognosis. Methods: The tonometer was placed on the cerebral cortex during operations in 43 patients--26 with severely head injury (GSC<8) and 17 with cerebrovascular disease from 1994 to 1998. We measure cortical cellular PCO₂ by using a tonometer whose catheter end had a silicone balloon permeable by CO₂ and arterial blood HCO₃^-. pHi was calculated by the Henderson-Hasserbalch equation from cortical cellular PCO₂ and arterial blood HCO₃^-. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were measured in all cases and jugular bulb oxygen saturation in 19. Outcome was estimated by the Glasgow Outcome Scale at hospital discharge and survivors divided into 2 groups--good (good recovery and moderate disability) and poor (severe disability and persistent vegetative state). We evaluated the relationship between pHi and patient outcome, pHi, and CPP. Patients were divided into 3 types by pHi course and we estimated patient outcome among these three types. Results: Of 143 measurements in 43 patients, the differences in pHi between survival and mortality was statistically significant (p<0.0001) but that between good and poor outcome was not. A direct correlation was seen between pHi and CPP (r²=0.40) and was significant in trauma patients (r²=0.524). Type A patients (pHi consistently more than 7.2) survived except for 3 who died from complications. All but one patient of type C (pHi consistently under 7.2) and 4 type B (pHi fell down under 7.2 in the course) died. One type B patient survived due to swift treatment based on pHi decrease. SjO₂ did not correlate with pHi but if pHi exceeded 7.2, SjO₂ tended to be in the ideal range of 50-80% (p<0.05). Conclusion: Our results suggest that measurement of cortical cellular pH using an intracranial tonometer is useful in evaluating cerebral metabolism for neurointensive care patients and predicting patient prognosis.

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A 16-year-old female was admitted to another hospital with complaints of fever, non-productive cough and dyspnea. Despite treatment with β-lactam antibiotics, the patient's arterial blood gas analysis revealed severe hypoxemia, following which the patient was brought to our emergency department. On admission to our hospital, the arterial partial pressure of oxygen under the condition of 10l/min. O₂ inhalation was 48mmHg, and a chest roentgenogram revealed bilateral wide-spread infiltrative opacities. Under the diagnosis of atypical pneumonia associated with acute respiratory distress syndrome (ARDS), we started treatment with administration of minocycline, erythromycin and corticosteroids, mechanical ventilation and continuous hemodiafiltration. Consequently, the chest roentgenogram and hypoxemia gradually improved, and mechanical ventilation was discontinued on five day after admission. The serum titer of a complement fixation test against Chlamydia on the day of admission was revealed as 1:128 on day 8 post admission. In addition, on interviewing the patient, we discovered that doves had made a nest on the veranda of the patient's house. Therefore we made a final diagnosis of psittacosis associated with ARDS. Psittacosis should be considered as a possible cause of ARDS necessitating intensive care including mechanical ventilation.

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A 64-year-old male victim of a traffic accident was admitted to our hospital. On admission, cholinesterase (ChE) (measured as pseudo-ChE) level was abnormally decreased to 59U/l (normal range 3600-7000U/l). There had been no exposure to substances which inhibit ChE activity such as organic phosphorus compounds. Among his relatives, a younger brother showed a similarly abnormally low ChE level. Other brothers and a few relatives had mild hypocholinesterasemia. Genetic analysis revealed a mutation from Gly (GGA) to Arg (CGA) at the exon 2-codon 365. The patient and his younger brother with hypocholinesterasemia had homozygotes, while one of his daughters had heterozygotes. In these cases, administration of suxamethonium chloride should be avoided. Furthermore, if patients with this disease had been intoxicated with organic phosphorus, it would be difficult to evaluate the severity of the poisoning by determination of plasma pseudo-ChE level. The essentially low ChE level may lead to the a wrong decision regarding the therapeutic modalities. Therefore, emergency physicians should recognize the presence of this disease.

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