目的:心肺機能停止(CPA)蘇生後脳症の転帰改善に対する低体温療法の有効性を検討する。対象と方法:1995年11月より1999年10月に18～80歳の頭蓋内出血を除く非外傷性院外CPA患者で入院後24時間以上生存した57例を対象とし,retrospectiveに調査した。低体温療法を行った23例(TH群)と行わなかった34例(n-TH群)で諸要因と入院1か月後のcerebral performance categories (CPC)を取り上げ,ロジスティック回帰分析を用いてCPCと相関する因子を検討した。結果:TH群の平均年齢は48.7±15.5歳,n-TH群は64.5±10.9歳(p<0.01)。TH群の院外心拍再開(oh-ROSC)例は7例(30%),n-TH群で3例(8%)あった(p=0.07)。転帰良好例(CPC=1, 2)はTH群で6例(26%),n-TH群で3例(9%, p=0.14)。転帰良好の9例はすべてoh-ROSC症例で,ロジスティック回帰分析では,「oh-ROSC症例か否か」のみが転帰に対して有意な相関があった。結論:本研究ではCPA蘇生後脳症の転帰改善に対する低体温療法の明らかな有効性は確認できなかった。

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非外傷性に胸部不快感を訴えている患者の12誘導心電図を院外で記録し電話で電送できれば,患者のトリアージに役立つと考え検討した。救急救命士は現着時に患者の病状が安定していることを確認し,承諾を得たあと救命指導医に電話で連絡した。指導医が適応ありと判定した205例を対象として,救命士は心電図を救急車内で記録した。心電図はアナログからデジタルへ変換され,自動解析後に携帯電話にて電送された(NEC社製)。その心電図は指導医の待機する消防指令センターでプリントアウトされた。その結果,2例は電送不能で2例は搬送を拒否したため,残る201例では心電図の記録開始から現場出発まで平均10.5±7.8分を要した。指導医は各症例で主訴と心電図所見より初期診断し,患者のトリアージを行った。搬送した医療機関での最終診断は狭心症36例,急性心筋梗塞27例,心不全23例,不整脈21例であり,全体の53.2%を心疾患が占めた。心電図自動解析の結果は狭心症例では38.9%がST. T波異常で,27.8%が不整脈であった。急性心筋梗塞例では40.7%がST. T波異常で,14.8%でしか急性心筋梗塞と診断できなかった。心不全例では30.4%がST. T波異常で,26.1%が不整脈であった。しかし不整脈例では52.4%を不整脈と診断できた。指導医による初期診断の精度(感度と陽性適中率)を最終診断より顧みると,狭心症例では50.0%と54.5%,急性心筋梗塞例では74.1%と64.5%,心不全例では34.8%と61.5%,不整脈例では66.7%と58.3%であった。すなわち,急性心筋梗塞例と不整脈例とでは有意差を認めなかったが,急性心筋梗塞例の初期診断精度は,1誘導心電図電送でも診断可能とされる不整脈例より良好であった。以上より,今後より多くの心疾患患者で12誘導心電図電送が活用されるには,心電図記録開始から現場出発までの時間を短縮し,急性心筋梗塞患者での診断精度向上に向けての自動解析ソフトの更新が必要と思われた。

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化学災害は,いったん起こると地域社会に甚大な影響を与える。そのなかで医療機関は,化学兵器テロリズムをも含めた化学災害対応の強化を迫られている。そこで本邦における医療機関,消防機関の化学災害に対する準備状況の現況を調査し,今後の化学災害対応強化の方策を考察した。東京都および政令指定都市の消防機関,各都道府県の災害基幹医療センターの計65機関に向けて化学災害対策の実態をアンケート調査し,84.6%の回答を得た。消防機関では,90.9%が高速道路上の化学災害を想定し,81.8%が化学工場での事故,72.7%がテロリズムとしての化学災害を想定し,化学災害を想定していない機関はひとつもなかった。一方,医療機関では高速道路上の化学災害を想定しているのは20.5%,化学工場での事故は18.2%,テロリズムの想定は13.6%に過ぎず,まったく化学災害を想定していない医療機関も68.2%におよび,関心の低さが目立った。また消防機関ではすべてが化学災害マニュアルを有していたのに対し,医療機関で有している施設はひとつもなかった。個人防護装備の配備状況では,消防機関は100%配備されていたが,医療機関では4.5%に過ぎなかった。また,個人防護装備,廃液の貯留,臥位対応の除染の三条件を満たす集団除染システムをもっていたのは,医療機関,消防機関を通じて皆無であった。集団除染システムを採用できていない最大の理由は,医療機関,消防機関共に予算の不足であった。消防機関では,医療機関に比べて化学災害への認識が高いものの,集団除染を消防の責務とすべきかどうかはっきりしておらず,集団除染の責任の所在を明確にすることが必要であると思われた。今年度中には,医療機関に除染設備,個人防護装備の配備が開始されるが,今後,医療機関では,まずは化学災害を想定することから始め,化学災害マニュアルの策定や定期的かつ実際的な化学災害訓練を含めた集団除染運営上の努力が望まれた。

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Iodoformgauze topical applications are often used to wound infections. We report a postoperative epidural abscess with delirium due to iodoformgauze topical application in an open wound. We had inserted an epidural catheter in 79-year-old man with an epidural abscess. After proper drainage, iodoformgauze was used to cover for the abscess. He suffered consciousness disturbance for 12 days postoperatively. Suspecting iodoform toxicity, we checked protein binding iodine (PBI) and total serum iodine. PBI was 14.5μg/dl and total serum iodine 152μg/dl. We stopped iodoformgauze use, and the man's consciousness cleared, indicating the importance of watching for side effects such as consciousness disturbance when using iodoformgauze.

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A 75-year-old man who developed fatal Legionella pneumonia due to near drowning was transferred to our medical center because of severe hypoxia (P/F 46.8). His pulmonary oxygenation was gradually improved (P/F 482 on day 7) by mechanical ventilation, then his respiratory condition deteriorated rapidly (P/F 57.60 on day 10) with high-grade fever, leucocytosis, and increased CRP. Chest radiography showed severe interstitial and pulmonary infiltrates in almost all of the lung field. To avoid high-pressure mechanical ventilation and highly concentrated oxygen inspiration, V-V bypass extracorporeal lung assist (ECLA) was begun and bronchoalveolar lavage (BAL) was conducted on day 11. Legionella pneumophila serogroup 6 (LPSG6) was detected from BAL fluid and clarithromycin and rifampicin administered orally for 4 weeks. Serum antigen titer for LPSG6 and Legionella dumoffii was×512 on day 23. In his clinical course, ECLA was done twice (from day 10 to 23 and from day 37 to 47). He recovered and was discharged on day 116. Legionella pneumonia caused byLPSG6 and L. dumoffii is still rare. In Legionnaires' disease, these pathogens must be considered and serological and/or culture diagnosis made early in the clinical course.

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Hemodynamic stroke (HS) is defined as cerebral infarction caused by cerebral hypoperfusion with systemic hypotension involving perioperative complications of cardiovascular surgery, cardiogenic shock, and severe carotid stenosis or occlusion. HS theoretically should occur in trauma patients with severe hemorrhagic shock, but clinical reports of HS are rare. We report 4 patients with HS following severe hemorrhagic shock due to trauma in the absence of head or neck injury. These cases suggest that cerebral damage resulted from a generalized reduction in cerebral blood flow secondary to hemorrhagic shock caused by trauma, which required massive blood transfusion. Computed tomography (CT) should that 3 patients had cerebral arterial boundary zone infarction and 1 had an infarction in the territories of the bilateral posterior cerebral artery (PCA). Magnetic resonance (MR) angiography conducted in 3 patients confirmed that none had detectable stenosis or occlusion of the bilateral internal carotid arteries (ICA), vertebrobasilar arteries, or large intracranial arteries. The cerebral arterial boundary zone and territory of PCA are known to be vulnerable to profound hemodynamic disturbance because of insufficient collateral supply. These findings suggest that severe posttraumatic hemorrhagic shock, in the absence of ICA stenosis or large intracranial arterial stenosis, is likely to produce HS. These cases highlight the critical importance of systemic resuscitation in all cases of trauma to prevent secondary brain damage.

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An 81-year-old male was transferred from a local hospital because of leukocytosis and the finding of abdominal guarding on physical examination. Abdominal X-ray and CT revealed marked dilatation of the ascending and transverse colon, with a large amount of ascites. Under the preoperative diagnosis of diffuse peritonitis secondary to colonic obstruction, an emergency laparotomy was performed. At operation, the transverse colon was found to be twisted 360° counterclockwise, with ischemic changes, and was resected partially and anastomosed without colostomy. The postoperative course was uneventful. In a review of the literature, there have been 40 cases of volvulus of the transverse colon reported in Japan, thirteen of which were in subjects with mental retardation or chronic constipation. Twenty-one patients were diagnosed correctly by contrast enema, which is considered clinically useful for the diagnosis. Laparotomy was perfomed in 37 cases, while nonoperative reduction was carried out in 5, including two who underwent palliative colostomy. Etiologically, elongation or hypermobility of the transverse colon has been reported to predispose to volvulus. In 2 cases among ten with a history of laparotomy, adhesion was noted to be the axis of the volvulus, and in 5 other cases, a band caused the volvulus, regardless of the operative history. In our case, chronic constipation and senile dementia might be implicated in the genesis of the volvulus.

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Pulmonary thromboembolism (PTE) after air travel, firstly reported by Symington in 1977, is also called “economy class syndrome.” We recently treated 3 such cases after patients took long-haul flights. All 3 were Japanese women arriving in Japan after 11.7 to 13.5 hours of flight in economy class. Their major symptoms were dyspnea, convulsion, and loss of consciousness. All had risk factors such as obesity, age greater than 40 years, and immobilization in a cramped seat. One took oral contraceptives and another had antiphospholipid syndrome. All 3 were immediately diagnosed with PTE, thanks to findings of ultrasonic echocardiography and computed tomography (CT). They were treated with heparin and immediately transferred to a university medical center. All were eventually discharged with no apparent adverse sequelae. The number of passengers who travel overseas is rapidly increasing. Although the occurrence of deep vein thrombosis and subsequent PTE is very rare, it is serious and may be life-threatening, so the possibility of its occurrence must be kept in mind.

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