We studied out-of-hospital cardiac arrest witnessed by emergency medical technicians (EMTs) based on Utstein recom-mendations. Among 5, 047 such arrests in Osaka prefecture from May 1, 1998, to April 30, 1999, subjects were 312 witnessed by EMTs after collapsed. In 175, cardiac arrests were of cardiac cause. In the remaining 137, cardiac arrests were of noncardiac cause. One-year survival was 6.2% (11/175) in arrests of cardiac cause and 4.4% (6/137) in those of noncardiac cause. Compared data from regions including New York, Helsinki, and South Glamorgan in the UK, the incidence and survival of such arrests of cardiac origin witnessed by EMTs was low. In the 175 of cardiac cause, only 30 showed ventricular fibrillation or ventricular tachycardia (VF/VT) in initial rhythm. A low incidence of VF/VT was noted related to this low survival. Among 30 arrests of VF/VT, only 12 underwent defibrillation (40%). It took 5.7±4.9 minutes for ambulance personnel to defibrillate from arrest onset. The incidence and survival of arrests of noncardiac cause were similar to results of the Helsinki study, so the low survival of arrests of cardiac cause in our region is related to the low incidence of VF/VT causes and the delay in defibrillation by EMTs.

View full abstract

Narita Red Cross Hospital is located near the New Tokyo International Airport and has many occasions to treat foreign travelers with acute severe illness. We retrospectively studied 82 such cases (50 men and 32 women, age 15-82y/o, mean of age 47.7y/o) admitted to the Narita Red Cross Hospital Emergency Center over 8 consecutive years (1993-2000). The number of patients from the U.S. was 31, the highest. Patients from East Asia numbered 29, and nations from which patients came numbered 22. Some 55 patients spoke English, but communication was the most serious problem in 24 who did not speak English. In these cases, it was almost impossible to take history, get informed consent, explain the disease, or understand complaints. Diseases included gastrointestinal disease (GI tract bleeding, perforation, ileus, acute appendicitis etc.) 22%, cardiovascular disease (acute myocardial infarction, heart failure) 16%, trauma 18%, disease of central nervous system (cerebrovascular accident, epilepsy etc.) 15%, respiratory disease (respiratory failure, pneumonia etc.) 7%, other diseases 22%. Eighteen patients (22%) were treated in the ICU/CCU. Disease was treated in 62 cases, unchanged notably in 10 cases, and involving simple treatments were 3 cases. Overall, 7 died. Many wanted to be discharged and go home as soon as possible, admissions were relatively short. Patients admitted for less than 21 days numbered 70 cases (85%). Twelve patients needed medical attendance (doctor and/or nurse) and 20 needed nonmedical assistance (family or a person concerned) for travel home. During travel, 13 patients required a wheelchair and 7 a stretcher. Such medical practice forces the hospital staff to make unusual efforts in verbal communication and in managing early repatriation. The hospital sustains some economic loss with patients without medical insurance. More effective support should therefore be considered by the administration.

View full abstract

Objective: We clarified the frequency and clinical features of alcoholic ketoacidosis (AKA) and alcoholic ketosis (AK) in the emergency room of a Japanese hospital. Subjects and Methods: 1) We prospectively evaluated blood gas analysis, serum ketones, and urine ketones by dipstick among alcohol-related disorders in 940 patients at the Department of Emer-gency and Critical Care Medicine at Keio University Hospital in 3 months. 2) We retrospectively evaluated AKA among alcohol-related disorders registered in a database of 27, 952 patients at the same Department in the last 11 years: AKA was defined as metabolic acidosis with either high serum ketones or positive dipstick of urine ketones in heavy drinkers. Results: 1) Alcohol-related disorders were found in 16 patients (1.7%). AKA was diagnosed in 2 of the 16 (13%). Seven of the 16 (43%) showed both ketosis and low ratio of serum acetoacetate/β-hydroxybutyrate. 2) Alcohol-related disorders were found in 210 patients (0.8%), out of whom 9 (4%) met the criteria of AKA. All AKA patients were men. The most commonly complaint was consciousness disturbance. Some 73% had hypoglycemia and 36% hypothermia. Dipstick test of urine ketones showed high false-negative results (55%) due to low ratio of serum acetoacetate/β-hydroxybutyrate. Conclusion: Intensive evaluation of blood gas and serum ketones among heavy drinking patients in the emergency room showed that AKA and AK are common disorders. The clinical features of AKA in this study were, in part, similar to those of alcohol-related sudden death syndrome.

View full abstract

Background; No study has been reported regarding whether an area or institution meets recommendation criteria for the introduction of public access defibrillation program (PADP) in Japan, so the appropriateness of its introduction remains to be established. Objective; The occurrence of cardiac arrest in Funabashi, Chiba, will be studied to assess the appropriateness of this area or institutions for PADP introduction. Methods; Funabashi City covers an area of 85.64km² and has a population of 550, 079. The population 65 years of age or above is 68, 878, accounting for 12.6% of the city's population. In 700 cases of cardiac arrest for which an ambulance was called from April 1998 to March 2000, a retrospective investigation was conducted based on the Utstein style, using Ambulance Records of Funabashi. We assessed whether the frequency of attempted resuscitation for cardiac arrest meets the criterion of no less than 1 case per 1, 000 population per year, and whether the appropriate application of automated external defibrillators (AED) can be expected at least once in 5 years in each institution, whether witnessed primary cardiac arrest is expected to occur at least once in 5 years. In addition, the frequency of witnessed cardiac arrest was investigated by selecting the following 3 types of large institutions in 4 locations: LaLaport Ski Dome SAWS, Funabshi Autorace Circuit, and 2 racetracks -JRA Nakayama racetrack and Funabashi racetrack. Results; There were 492 cases of attempted resuscitation for cardiac arrest, and the frequency was 0.45 case per 1, 000 population per year, not meeting the criterion. The frequency of witnessed primary cardiac arrest at the station, nursing homes and clinics was less than 1 case in 5 years, not meeting the criterion. In large institutions, the frequency of witnessed primary cardiac arrest was 0.35-1.33 cases per 1 million. In these institutions, the frequency of witnessed primary cardiac arrest was calculated to be more than 1 case in 5 years, meeting the criterion. Conclusion; We concluded that the area of Funabashi, Chiba, cannot be recommended for the introduction of PADP. We found the large institutions investigated to be recommendable for PADP introduction. At race tracks, since physicians are present on race days, it is considered useful to introduce AED on for the physician's use, even in the present situation.

View full abstract

We investigated the efficacy of local fibrinolysis, using a new technical innovation, for the treatment of acute ischemic stroke patients. Seventy-seven patients (83 occlusions) were treated using a local intra-arterial injection of urokinase (UK) or pro-urokinase (pro-UK). The occlusions consisted of 23 atherothromboses and 60 cardiogenic embolisms; the mean age of the patients was 69.5 years. A suitable guidewire or fibrinolytic agent was used, depending on the occlusion site, and piercing was frequently performed. UK was injected using a small syringe (2.5cc). The mean recanalization time was 215.3 minutes, and the recanalization rate was 83.1%. Hemorrhagic infarction developed in 11 cases (13.2%), and this event influenced the outcome. Patients with occlusions of the insular segment of the middle cerebral artery (M2) had a good outcome, regardless of collateral flow. Based only on the duration of ischemia, we considered that aggressive treatment was effective in patients with M2 occlusions. However, patients with occlusions of the distal horizontal segment of the middle cerebral artery (M1) or the basilar artery (BA) had a good outcome only if a sufficient residual blood flow was present. Patients with occlusions of the internal carotid artery (ICA) or the proximal M1 had a poor outcome, regardless of collateral flow. In our study, local fibriolysis was most effective when performed within 4 hours of occlusion onset. Thus, we conclude that the outcome of local fibrinolysis treatment will be improved as technical innovations enable a good recanalization rate to be achieved and the duration of surgery to be shortened.

View full abstract

A 24-year-old healthy man was admitted with hemorrhagic shock due to amputation of the bilateral lower limbs. After the first operation on limbs, hyponatremia with sodium wasting and circulatory instability developed on hospital day 2; endocrinological examination showed hypoaldosteronism and subsequently positive left femoral open-wound culturing followed by a persistent septic state. The absolute low value of cortisol and weak response to the rapid ACTH test helped us to diagnose absolute adrenal insufficiency (AI). Refractory hyperdynamic shock was promptly reversed by treatment with intravenous hydrocortisone and we debrided and surgically closed the left femoral openwound that was the source of sepsis. Several authors have shown that serum cortisol concentration is usually high and absolute AI is rare in sepsis. Due to the lack of specific signs and symptoms in AI, it is difficult to distinguish it from septic shock. Our experience shows the utility of endocrinological examination, including rapid ACTH and CRH tests in the diagnosis of sepsis-induced AI and their results show that AI in septic patients appears to be related to both primary and secondary failure.

View full abstract

We report a case of bleeding from an arteriovenous malformation of the terminal ileum. A 69-year-old man who underwent mitral valve replacement surgery for mitral stenosis and aortic stenosis suddenly experienced anal bleeding on postoperative day (POD) 61. We diagnosed extravasation from the arteriovenous malformations (AVM) of the terminal ileum by angiography. Transcatheter arterial embolization (TAE) using a tornado coil was undertaken and surgery conducted 7 days later. During surgery, we easily found the coil that revealed the bleeding point using intraoperative fluoroscopy. Preoperative TAE for small intestinal bleeding mat thus be useful for clarifying the bleeding point during surgery.

View full abstract