In 1991, we introduced percutaneous cardio-pulmonary support (PCPS) at our hospital as a way to conduct aggressive cardiopulmonary cerebral resuscitation for patients with out-of-hospital cardiopulmonary arrest, but the system under which the decision to apply PCPS is made at the hospital and preparations then made could exceed the time limitations imposed for cerebral resuscitation. Thus, we have collaborated with the physician-manned ambulance system, which has been in operation since 1995, and in April 2000 introduced a pre-hospital PCPS order treatment strategy for patients with out-of-hospital cardiogenic cardiopulmonary arrest, who do not respond to drug administration or electrical cardioversion. Under this system, PCPS is aggressively and rapidly instituted by having the physician-manned ambulance initiate the PCPS order and initiate hospital preparations for PCPS. In 13 patients treated under the pre-hospital PCPS order system, the mean time elapsed from arrival at the hospital until initiation of PCPS was 18.8min, and the minimum was 8min. In 45 patients for whom the decision to initiate PCPS was made at the hospital (in-hospital order), the mean time from arrival until initiation of PCPS was 43.7min. The outcome under the pre-hospital order system was full recovery in 5 patients, complete disability in 2 patients, and death in 7 patients, so the proportion achieving full recovery was 38.5% better than 13.3% in 45 patients treated under the in-hospital order system. In cardiopulmonary cerebral resuscitation, rapid return of stable cerebral circulation is critical for determining survival and functional prognosis. We believe that our system in which the physician-manned ambulance monitors the response to drug administration and electrical cardioversion and initiates the order to prepare for PCPS at the hospital is the most sensible treatment strategy to achieve a rapid return of stable cerebral circulation in cardiopulmonary cerebral resuscitation.

View full abstract

Delayed diagnosis of traumatic bowel injury often results in a poor outcome. In general, bowel injury is confirmed by detecting intraperitoneal free air by plain radiography, ultrasonography (US) and computed tomography (CT). Although CT has contributed a great deal to the speed and accuracy of diagnosis, it is sometimes difficult to judge whether small intraperitoneal-air-like shadows actually represent intraperitoneal free air. We encountered two rare trauma patients (19 year-old-man and 3 year-old girl) who were initially suspected to have bowel injury based on the finding of an air shadow adjacent to the thoracic cavity with features mimicking those of intraperitoneal free air in high-performance CT scans, which was eventually judged by us as representing intrathoracic air of the lung. Both the patients were transferred to our hospital because of the presence of an air shadow on the surface of right lobe of the liver, separated from the lung, in the initial CT scans, which was misdiagnosed as intraperitoneal free air. There were no other signs indicative of bowel injury in either case. We treated both patients conservatively, and both recovered satisfactorily. It is necessary to note that an intrathoracic air shadow surrounded by the diaphragm and ribs can appear as a virtual image of intraperitoneal free air in high-performance CT images scans.

View full abstract

A 19-year-old man was transferred to our hospital after sustaining multiple injuries in a motor vehicle crash. He had no history of previous blood transfusion. On arrival, he became hemodynamically unstable and required a splenectomy. Because of his hemodynamic status, he received several units of blood in the operating room and during his postoperative course. All together, a total of 75 units of blood was required. On the 28th postoperative day, he was noted to have acute hemoglobinemia and hemoglobinuria. A diagnosis of delayed hemolytic transfusion reaction (DHTR) was made because of the presence of anti-E antibody in the patient's plasma. DHTR is usually the result of extravascular hemolysis, and occurs within three weeks of blood transfusion. Since a splenectomy had been performed, we believe that hemolysis occurred in the blood vessels. Although the exact mechanisms of DHTR are not clear, potential sequelae such as hemoglobinuria and subsequent renal failure can be clinically devastating. For this reason, we should always be aware of the potential for developing DHTR when transfusing splenectomized patients.

View full abstract