狂犬病は予防できるが,治癒させられない代表的ウイルス性人獣共通感染症である。日本では1957年以降ヒトの狂犬病も動物の狂犬病も発生の報告はないが,狂犬病が常在する国々はいまなお多数ある。したがって,狂犬病が日本に侵入する可能性は常に考えておく必要がある。近年日本から海外に旅行ないし出張する人々は年間1600万人を超えた。こうした状況では狂犬病常在地への旅行者がイヌやネコなどに咬まれて狂犬病ウイルスに感染し,帰国後に狂犬病を発病する輸入狂犬病が発生する可能性は高い。日本では狂犬病ワクチンを常備する医療機関が少なく,狂犬病免疫グロブリンは製造も輸入もされていないため,海外での動物咬傷被害者に狂犬病曝露後発病予防を迅速に実施できる状況にない。日本での輸入狂犬病発生を防ぐためには,医療機関における狂犬病への備えが必須である。

抄録全体を表示

近年頭部外傷において,受傷早期のカテコールアミンの大量分泌が血圧上昇と心拍数増加を伴い,内分泌学的観点における予後不良因子であると指摘されているが,現在のところ他の血清ホルモン値についての定説はないと考えられる。受傷後当院救急医療センターへ直接搬送され,初回頭部computed tomograpy(以下CT)検査で頭蓋内出血が確認された,血圧低下のない単独頭部外傷症例14例(男性11例,女性3例)について,病院到着時のカテコールアミン,下垂体ホルモン,甲状腺ホルモンおよび副腎皮質ホルモンを測定した。また,1か月後の生死により14例を2群に分類し,年齢,受傷から病院到着までの時間,病院到着時のGlasgow coma scale(以下GCS),血圧,心拍数,shock index(以下SI),各種ホルモン値について各群毎に比較検討を行い,さらに上記の項目と各ホルモン値の間の関係を調べた。死亡群では生存群に比し,有意にGCSが低値でアドレナリン,ノルアドレナリン,甲状腺刺激ホルモンが高値を示し,副腎皮質刺激ホルモンが低値であった。また統計学的には有意とならなかったが,血圧上昇と共に心拍数が低下,すなわちSIが低下する傾向が認められた。生存群においてこのSIの低下とアドレナリンとの間,死亡群では主に甲状腺刺激ホルモンとthyroxine(以下fT4)との間に統計学的に有意な関係を認めた。甲状腺刺激ホルモンとfT4の間には直線的関係が認められたが,その様式は2群で異なっていた。今回の検討で死亡群に認められたSIと下垂体-甲状腺系ホルモンとの関係について,今後症例数を増加すると共に,その因果関係を明らかにしていく必要があると考えられた。

抄録全体を表示

人工呼吸器管理を行う上で人工呼吸器関連肺炎(ventilator-associated pneumonia; VAP)の発症を抑えることは重要な課題である。VAPの予防法としては様々な報告がなされているが,本邦においてはVAPを予防するためのガイドラインは存在せず,おのおのの施設で独自に管理されているのが現状である。そこで,VAP予防の一環としての人工呼吸器の管理方法について再確認が必要と考えられ,全国157か所の救命救急センター付属のICU(以下救急センターICU)へ向けて人工呼吸器管理についてのアンケート調査を行った。集中治療室におけるVAPのサーベイランスは,米国疾病対策センター(Centers for Disease Control and Prevention; CDC)のガイドラインにおいて,VAPを予防する上で最重要視されているが,今回の調査で実施していると答えた施設は,全体の7.8%に過ぎなかった。人工呼吸器回路の交換頻度では,CDCのガイドラインでは推奨していない48時間以内での交換も5.4%にみられた。米国では,回路内の結露を定期的にウォータートラップへ落とすことが推奨されているが,今回の調査で定期的にこれを行っている施設は30.4%で,67.0%が気付いたときに落とすと答えていた。開放式の喀痰吸引を行っている施設で,滅菌グローブを着用している施設は49.1%であり,19.6%はグローブの着用なしに処置がなされていた。処置後の手指洗浄が徹底されていないとの返答も16.1%にみられ早急な改善が望まれた。本邦においては,施設間で人工呼吸器の管理方法にばらつきがみられ,VAPの発症予防のための人工呼吸器管理における統一ガイドラインの策定が必要であると思われた。また,ガイドライン作成のエビデンスを固めるためにも,救急センターICUでのサーベイランス導入は欠かせないものと思われた。

抄録全体を表示

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.

抄録全体を表示

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.

抄録全体を表示

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.

抄録全体を表示

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.

抄録全体を表示

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.

抄録全体を表示

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.

抄録全体を表示