1996年1月から2000年12月までの5年間に当院救急部を救急車で受診した発症24時間以内の急性心筋梗塞(AMI)患者の背景と治療成績を検討した。全患者数15,896人中AMIは107人(0.67%)であり,東京地区での推定発症頻度とほぼ同程度であった。これは当救急部が循環器疾患や重症傷病に特化せず,あらゆる傷病を重症度を問わず診療するという「北米型のER」の形態をとっていることを反映していると考えられた。発症から来院までの時間は平均209±245分,中央値123分であり,94%は12時間以内の到着であった。他院への転送例4人,外来死亡2人を除く101人が入院し,うち86人(85%)に緊急心臓カテーテル検査が施行され,81人に緊急冠動脈形成術が施行された。病変成功(TIMI2以上)は76人(94%)で得られた。経静脈的血栓溶解療法は1人のみに施行された。院内死亡は11人(10.7%)で,再灌流療法施行例では4.9%であり,内外の報告と比較し遜色のない治療水準を維持していた。また救急部門と循環器医との効率的な連携のために導入したクリティカルパスが有効に活用されていることも確認された。

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背景:本邦における院外心原性心肺停止の生命機能予後に及ぼす経皮的心肺補助(PCPS)を用いた積極的治療の意義は必ずしも明確でない。目的:当施設での治療成績を検討し,PCPSを用いた治療の効果を明らかにすることを目的とした。対象と方法:1999年4月から3年間に当救命救急センター搬入となった心原性心肺停止連続187例(男性128例,女性59例;年齢65.5±16.3, 3-94歳)を調査対象とし,急性期生命転帰および機能障害の程度と,これに影響を及ぼす諸因子について検討した。結果:(1)搬入後の治療はPCPS 20例(11%),大動脈バルーンパンピング(IABP) 19例(10%),緊急冠状動脈造影18例中10例に経皮的冠状動脈インターベンション(PCI)を施行,脳低温療法は20例(11%)に施行した。心原性全体で心拍再開率32%,生存率14%,機能良好9%であった。(2)心拍再開もしくはPCPS装着による臓器血流再開時間は機能良好例では平均30.9分で,死亡例,高度障害残存例に比し有意に短かった。(3)治療にPCPSを必要とした20例と,PCPSを用いずに心拍再開した21例(搬入時pulseless electrical activityと心静止は除外)の入院30日後の“機能良好:高度障害残存:死亡”の割合は,PCPS群35%:15%:50%,非PCPS群38%:19%:43%で両群間に有意差を認めなかった。結語:臓器血流再開までの時間が短い症例では,機能回復は比較的良好であり,発症早期にPCPSを用いる積極的な蘇生治療は有効と考えられた。

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Using trepanation and surgical drainage, we successfully treated epidural and subdural empyema caused by acute frontal sinusitis. An 11-year-old girl admitted for fever and right hemiparesis was found in head MRI to have epidural empyema of the left frontopolar region and subdural empyema of both the left convexity and interhemisphere following acute frontal sinusitis. Antibiotics started immediately after admission and frontal sinusectomy proved effective for the epidural but not subdural empyema, necessitating radical surgery on hospital day 10. Two trepanations were made on the left frontal convexity and posterior paramedian portion and drainage tubes placed at each empyema site after sufficient irrigation. Subdural empyema thereafter diminished to where the patient could be discharged, mobile, with mild right hemiparesis on day 38. We speculated that the infection route was from the acute frontal sinusitis to intracranial lesions, with epidural empyema possibly developing via direct extension through communicating veins and the perivascular space of the posterior wall of frontal sinus. Subdural empyema may have been caused by retrograde thrombophlebitis of cortical bridging veins. If conservative therapy for subdural empyema is not successful, immediate surgical drainage is recommended.

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In the 4 years since Japan's organ transplantation law went into effect, 22 organ procurements have taken place. To analyze problems in organ procurement from brain-dead donors, we reviewed the diagnosis of brain death and organ procurement in our 3 cases. 1) Although it signing and presentation of a donor card (“living will”) is generally regarded expression of definite intent of organ donation, this intent is not always fully discussed by family members. Procedures must proceed carefully until final decision-making for organ donation by family members. 2) To maximize respect for “living wills” in organ donation, we must reduce time taken for brain death diagnosis and organ procurement under legal guidelines and ensure organ viability. 3) The excellent results with organ transplantation surgery should be emphasized to improve organ transplantation awareness among potential donors.

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A 32-year-old man was compressed between two boards and suffered a pancreatic injury and acute blurring of vision. He was treated conservatively at a local hospital and transferred to our hospital on the 10th day following his injury. His corrected visual acuity was 0.08 for his right eye and 0.3 for his left. An ophthalmoscopy revealed multiple cotton-wool exudates and retinal hemorrhages, while a fluorescein angiography examination showed staining of the vessel walls and minor leakage along the vessels. We diagnosed the patient as having Purtscher's retinopathy and managed the patient by observation. Endoscopic retrograde pancreatography and computed tomography examinations revealed a disruption of the main pancreatic duct and a right renal infarction. A caudal pancreatectomy and a right nephrectomy were therefore performed on the 18th day after the injury. The visual acuity improved to 0.8 in the right eye and 1.0 in the left eye 5 months after the injury. Purtscher's retinopathy is characterized by a sudden loss of vision after a head, chest or abdominal injury and is associated with cotton-wool exudates and retinal hemorrhages in the posterior pole. No effective treatments have been reported, but the prognosis is typically considered to be good. Emergency doctors should be aware of this disease as a cause of blurred vision resulting from extraocular injury.

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Proximal occlusion or trapping combined with EC-IC (extracranial intracranial arterial) bypass is the treatment of choice for giant fusiform aneurysms if the parent vessel cannot be reconstructed by clipping. Combining endovascular treatment and bypass surgery is a viable alternative. We report a young man with mild right hemiparesis following a second episode of basal ganglia hemorrhage and subarachnoid hemorrhage. 3D-CT showed a left ruptured, partially thrombosed giant M1 fusiform aneurysm. He underwent STA-MCA bypass with attempted M1 reconstruction and, a week later, attempted total coil occlusion of the M1 aneurysm. Only the ruptured point at the distal M1 was occluded, however, resulting in temporary mild right hemiparesis and aphasia. A month later, when he was to undergo a second coil procedure, angiography showed spontaneous, complete obliteration of the M1 aneurysm, so no further endovascular procedure was attempted. The treatment of M1 giant fusiform aneurysms and the mechanism of spontaneous thrombosis of the aneurysmal sac after bypass and distal occlusion are discussed. Combined distal bypass and endovascular obliteration of the aneuysmal sac with coils is a variable alternative if vascular reconstruction is difficult or not possible.

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