目的:病院内で心停止に早期除細動を実践するには,看護師による電気的除細動(DC)が不可欠であるが,多くの看護師はDC施行を躊躇してきた。本邦に看護師によるDCを普及させるには,看護師がDC施行を躊躇する原因を明らかにする必要がある。本研究の目的は,看護師によるDC施行に対する看護師の態度に関与する要因を明らかにすることである。方法:平成15年10月に,救命救急センターを併設する市中総合病院(644床,看護師555人)で行われた救急蘇生法に関する院内講演会に先立ち,出席した看護師242人を対象に無記名アンケート調査を行った。有効回答が164人から得られた(回収率67.8%)。アンケートでは,評点尺度法を用いた9問を用意し,看護師によるDCに関して,教育,経験,法解釈および態度について尋ねた。病院内でVFへの遭遇時に,医師の指示なしでDCを施行するか否かについての態度に関与した要因をcategorical regression analysisを用いて抽出した。結果:VF遭遇時に,医師の指示なしでDCを施行すると回答した看護師は21人(12.8%)であった。この回答に関与した要因は,看護師による緊急時のDC施行は許されているか否かについての法解釈,DCの施行経験,DC施行現場への遭遇経験,および卒前教育の有無であった(r=0.476, p=0.02,重要度:0.444, 0.202, 0.126, 0.111)。結語:医師の指示なしでDCを施行するか否かに関する看護師の態度に最も関与した要因は,看護師のDC施行に対する法解釈であった。本邦において,看護師によるDC施行を普及させるには,看護師によるDC施行の法的根拠を明確に示す必要がある。

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We report that serial diffusion weighted imaging (DWI) is clinically useful in an epilepsy patient. A 63-year-old man was admitted in an emergency with status epilepticus and consciousness disturbance. CT scan and conventional MRI showed no abnormal area. DWI revealed the focal lesion as high intensity area in the parietooccipital area. Also, periictal EEG showed a focal epileptiform discharge in the same area. DWI was repeated for 5 consecutive days. The size of high intensity area seen on DWI decreased day by day. It therefore seemed reasonable to conclude that the high intensity area in the DWI in this case was the epileptogenic focus. The change in DWI findings in epilepsy is similar to the findings in cerebral ischemia. However, the mechanisms resulting in these finding may be different from those associated with ischemia. In status epilepticus, the metabolism is markedly increased, resulting in depletion of energy reserves in the later stage. This will result in impaired ion exchange pump functions and swelling of neuronal and glial cells. Serial DWI can be useful diagnostic method for localization of the focus in the evaluation of cases with epilepsy.

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We present a rare case of traumatic atlantoaxial rotatory subluxation in an adult. A 63-year-old woman developed hypovolemic shock after sustaining a left hemothorax, fractured ribs, a pelvic fracture and a fracture of the right fibula in a motor vehicle accident. Consciousness disturbance and right hemiparesis were found after recovery from the shock at another hospital and a head computed tomography (CT) disclosed intracranial hemorrhagic lesions. The patient was transferred to our hospital. The patient presented with torticollis and a neurological examination revealed mild consciousness disturbance (Glasgow Coma Scale E3V4M6) and right hemiparesis. A head CT showed the contusion in the left temporal region and intraventricular hemorrhage. Magnetic resonance image (MRI) disclosed diffuse axonal injury at the splenium. Cervical X-ray and CT revealed atlantoaxial rotatory subluxation. Cervical MRI disclosed a spinal cord injury at the C4 level. After cervical traction, the torticollis improved and administration of steroids and hyperbaric oxygenation therapy were effective for the right hemiparesis caused by the spinal cord injury. Diagnosis of injuries in the upper cervical spine is very important but sometimes difficult in patients with multiple traumatic lesions. The possibility of this lesion must be considered when seeing a patient with multiple traumatic lesions, especially when presenting with head trauma and consciousness disturbance.

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We report a case of impalement injury in a patient who was saved by using an intra-aortic balloon occluder (IABO). A 66-year-old man fell from the height of 3m, and was penetrated his body from left thorax to pubes by an iron column. He was transferred to our emergency department because of hemorrhagic shock. He was inserted the thoracostomy tube to left thorax for left pneumothorax, and intubated. His blood pressure was stable for blood transfusion, but IABO was inserted because massive hemorrhage was expected. Computed tomography (CT) scans revealed that the iron column was through left thorax to pubes, and suspected injury of left external iliac artery and vein. Just after CT scans, suddenly his blood pressure fell with tachycardia. Immediately IABO was inflated, his blood pressure was increased. Under the support of IABO, the operation including partial resection of left external iliac artery, ligation of left external iliac vein, repair of the serosa of sigmoid colon, cyststomy and gauze packing, were performed. After the operation, his vital signs were stable. He was discharged from the ICU on the 12th hospital day.

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