Rabies is a preventable, but incurable, infectious disease caused by the rabies virus that belongs to the genus Lyssavirus of the family Rhabdoviridae. Although no human or animal rabies cases have been reported in Japan since 1957, rabies is still endemic in many countries. The possibility that rabies may invade Japan must therefore be kept in mind. Recently, more than 16 million Japanese people travel abroad annually. Consequently rabies seems most likely to occur among travelers who return to Japan without proper post-exposure treatment after having been bitten by stray dogs or cats in rabies-endemic regions. Today in Japan, however, few medical institutions keep rabies vaccine in stock and thus cannot offer post-exposure vaccination to travelers bitten by animals in rabies-endemic areas. To ensure that deaths from rabies, especially imported rabies, improvement in the supply of post-exposure prophylaxis to travelers bitten by possibly rabid animals is strongly called for.

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A large amount of catecholamine secretion, with hypertension and tachycardia, is well known to be a poor prognostic factor in severe head-injured patients, but little is known about other hormone values. Systolic blood pressure, heart rate, shock index, and some hormones on arrival at our hospital were studied in 14 head-injured patients brought directly by ambulance without hypotension and with intracranial hemorrhagic lesion on initial computed tomography (CT). They are divided into 2 groups based on survival at 1 month. Blood samples were drawn through the central venous catheter or peripheral venous canula immediately on arrival before drug injection or infusion. In nonsurvivors--7 patients, all with acute subdural hemorrhage--systolic blood pressure seemes relatively higher and heart rate relatively lower than in survivors--7 patients, 2 with acute subdural hemorrhage, 3 with traumatic subarachnoid hemorrhage, 1 with brain contusion, and 2 with acute epidural hemorrhage. This trend is well recognized by the shock index (p=0.0639). Nonsurvivors secreted more adrenaline, noradrenaline, and thyroid stimulating hormone (TSH) and less adrenocorticotropin. In survivors, the shock index decreases correspondently to adrenaline secretion increase. In nonsurvivors, it decreased with thyroxine secretion decrease (p<0.05). In both groups, we found a significant relationship between TSH and thyroxine, but the relationship appears to differ by group. We must therefore clarify the relationship between the shock index, TSH, and thyroxine, especially in nonsurvivors.

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Suppressing ventilator-associated pneumonia (VAP) is important in managing mechanical ventilation in intensive care. Many preventive measures against VAP have been reported, but, as yet, no preventive guidelines exist for VAP in Japan. We sent questionnaires to 157 emergency centers nationwide to study management of mechanical ventilation. Surveillance, strongly recommended by the Centers for Disease Control and Prevention (CDC), is done at 7.8% of facilities surveyed. The change of ventilator circuits within 48hrs, prohibited by the CDC, is done in 5.4%. Regular dropping of condensate in the circuit to the water trap, recommended by the CDC, is done in only 30.4% of emergency centers. Suctioning sputum with sterile gloves is done in only 49.1% and without gloves in 19.6%. Some Japanese emergency center ICUs do have measures against VAP, but they are inconsistent. Guidelines for VAP prevention such as those of the CDC thus must be implemented as soon as possible in Japan. Introduction of surveillance in the emergency ICU is thought to strengthen evidence for the need for guideline preparation.

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We report an obscure case for diagnosis due to simultaneous appearance of varied, serious symptoms of fever, jaundice, skin erythema, increased monocytes, hepatic and respiratory failure, and disseminated intravascular coagulation syndrome (DIC). The case history showed self-medication of diaminodiphenyl sulfone (DDS) in addition to known prescribed medication, and the case was diagnosed as DDS syndrome. Clinical pharmacists can play an important role in diagnosis and treatment because of their complex knowledge of interactions and side effects of a broad range of different drugs. For this reason, clinical pharmacists have been invited to participate in daily ICU conferences at Hiroshima University Hospital since 1998. We describe a case with DDS syndrome in which the contribution of the clinical pharmacist was vital to patient diagnosis and treatment. The diagnosis of drug-induced side effects was determined based on data presented by the clinical pharmacist.

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A 60-year-old male presented with syncope while driving and crashed his vehicle into an oncoming vehicle. After resuming consciousness, he was transported to the emergency medical center by ambulance. Although he did suffer any trauma, the patient exhibited bradycardia and hypotension. An ECG examination showed a complete A-V block. He was diagnosed as having experienced an Adams-Stokes attack derived from a complete A-V block associated with acute myocardial infarction. Following the administration of atropine and isoproterenol, his blood pressure rose to 105/54mmHg. He received an emergency coronary angiography and PTCA. The stenosis of the occluded right coronary artery #2 was improved to 50%. He was discharged on the 11th hospital day.

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We report a case of anaphylaxis induced by lafutidine. A 33-year-old man presented with an anaphylactic reaction after taking lafutidine, an H₂-receptor antagonist. He had been treated with lafutidine, cefotiam hydrochloride, serrapeptase, pranoprofen, aspirin, acetaminophen, clemastine fumarate, scopolia extract and sodium azulenesulfonate for tonsilitis at another hospital. He developed an anaphylactic reaction after taking all of the drugs. His symptoms at the time of admission included vomiting, dyspnea, a skin rash over the entire body, and circulatory collapse. He recovered from the anaphylaxis after treatment with methylprednisolone sodium succinate. We performed several tests to detect the causative drug (s). Patch tests and scratch tests for the various drugs were all negative. Challenge tests for the various drugs were also negative, with the exception of the lafutidine challenge. Severe side effects, including liver dysfunction and pancytopenia, have been reported in patients treated with lafutidine. This is the first report of an anaphylactic reaction induced by lafutidine. The present case suggests that challenge tests may be useful for detecting the causative drugs of type I allergies.

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Tissue transplantation, especially using cardiac valve allografts, remains uncommon in Japan. The major problem is a shortage of donors. To ameliorate this problem, we have begun explaining the necessity of tissue donation to families of patients who have died in our emergency department and confirm their willingness to have tissues donated. We report a case of donation of cardiac valves and thoracic aorta from a patient with no donor card. Although an eye bank and skin bank have been established in Japan, there is much need to establish banks for other tissues, such as cardiac valves and aortas, as soon as possible.

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A 56-year-old man caught between a farm tractor and a tree was brought by ambulance 20 minutes after thoracic trauma. In the emergency room, his blood pressure was 117/70mmHg, heart rate 140 beats/minute, respiratory rate 36 breaths/minute, and GCS score 11. He showed jugular vein dilation, absence of the right breath sound, and abnormal respiratory movements associated with right chest wall instability. He had flail chest and tension pneumothorax. Emergency thoracostomy was conducted and 350ml of blood drained initially and 500ml each consecutive 40 minutes. Immediate thoracotomy done in the operating room showed complete transection of the azygos vein in front of the dislocated 5th thoracic vertebra. Both distal and proximal ends of the azygos were ligated. We found only 23 cases, including ours, of azygos vein injury due to blunt trauma, most due to motor vehicle accidents. Sudden deceleration plays an important role in etiology. Our patient drove a tractor, and did not appear to sustain abrupt force. We assume that the azygos vein was torn by direct shear force from vertebra, a possibility to be kept in mind in diagnosing such trauma.

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A 50-year-old construction worker had been pressed down beneath a forklift truck and sustained cardiopulmonary arrest. Physical findings were typical for traumatic asphyxia. The patient was resuscitated by a bystander using only external cardiac compression; rescue breathing was not performed. He had both coma and cardiopulmonary arrest persisted for 7 min until emergency medical technicians (EMT) arrived. However, he was resuscitated in cooperation with bystander, EMT, a nearest hospital and our hospital on resuscitation. Nearly full recovery ultimately resulted. Even incomplete resuscitation performed immediately by a bystander may offer a better chance of survival and permit a better functional outcome in traumatic asphyxia than proficient but delayed cardiopulmonary resuscitation.

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