Background: The plasma level of D-dimer (DD) on admission is useful as a prognostic marker of head injury. Methods: Eighty patients with isolated blunt head trauma were grouped according to the type of brain parenchymal injury using MRI. The differences in the DD levels among the groups, and the correlation between the DD levels and the patients' outcome, were investigated. Results: All patients were categorized into the following groups: diffuse axonal injury (DAI, n=24), cerebral contusion (CON, n=47), and no intraparenchymal lesion (NIL, n=9). The DD level was significantly higher in the CON-group than in the other two groups. In the CON-group, the patients with an unfavorable outcome had significantly higher DD levels. In the DAI-group, however, the DD level remained generally low regardless of the outcome. Conclusions: The DD level was sensitive to the type of brain injury. In the DAI-group, however, the coagulation-fibrinolysis activity was not accelerated to as great an extent as it was in the CON-group, therefore even the DD level was not a good prognostic indicator.

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An association between hyperventilation syndrome (HVS) and mental disorders have not been well characterized in emergency settings. We reviewed the percentage, backgrounds, and psychiatric symptoms with HVS seen at a critical care center and addressed the role of psychiatrists. The study subjects included 116 patients with HVS presenting to an advanced medical emergency and critical care center in I prefecture between April 1, 2002 and August 31, 2003. On admission, 26 patients with a past history of psychiatric disease and 39 patients without were examined for psychiatric symptoms by psychiatrists. The number of visits by male and female patients with HVS accounted for 0.7% and 4.6% of the total visits at the critical care center, respectively. In both sexes, HVS occurred most frequently in individuals aged 20 to 29 years. More than half of the patients received a primary diagnosis of mental disorder according to the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision (ICD-9). All patients with a past history of psychiatric disease and 64% of patients without had a score of 70 or lower on the Global Assessment Scale, indicating decreased activity of daily living associated with psychiatric symptoms. On the Brief Psychiatric Rating Scale, mild to severe symptoms of somatic concern, anxiety, tension, and/or depression were observed in at least 50% of the patients with a past history of psychiatric disease, while mild to severe symptoms of anxiety and/or depression were noted in more than half of the patients without. Also, 69% of the patients with a past history and 31% of those without had depression as evidenced by a total score of 16 or higher on the 17-item Hamilton Rating Scale for Depression. In addition to HVS, stress related disorders were diagnosed in approximately 40% of patients with or without a past history on average, mood disorder in approximately 20% of patients in both groups, and panic disorder in 8% of those in both groups when patients were examined for psychiatric disorders on the basis of ICD-10. These results showed that patients with HVS represented a substantial part of emergency outpatients and had psychiatrically characteristic manifestations including anxiety and significant depression. In conclusion, medical care of patients with HVS at emergency and critical care centers requires stress management as well as early identification and treatment of depression. For this purpose, psychiatric specialists should preferably be involved in medical care from the first presentation.

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The American Heart Association has included the use of automated external defibrillators (AEDs) for early defibrillation by first responders as a standard of care for in-hospital ventricular fibrillation (VF). However, there are as yet no reports on the in-hospital early defibrillation program in Japan. To make the program successful, an early defibrillation capability by all nurses is essential. Recent studies have indicated that hospital nurses can easily use AEDs, because AEDs preclude the need for extensive training on ECG recognition, and there is also no fear of delivering shocks to a patient. Therefore, the use of AEDs can facilitate the introduction of the in-hospital early defibrillation program. Here, we report the case of a 70-year-old hospitalized man who developed an episode of VF outside our critical care area. Using AED, a nurse delivered shock to revert the VF, and succeeded in restoring the patient's circulation before the arrival of a physician. The delay between recognition of the VF and the delivery of the first shock was under 2 minutes. The physician arrived in the ward 74 seconds after the delivery of the shock. This case highlights the importance of the ability of nurses to successfully use defibrillation to strengthen the in-hospital chain-of-survival. The use of AEDs may thus promote the in-hospital chain-of-survival.

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We report a case of enterovesical fistula and abdominal abscess associated with diverticulitis of the small intestine. A 94-year-old man was admitted to our hospital with a history of loss of appetite and abdominal pain. Laboratory examination revealed marked elevation of the CRP to 21.8mg/dl and pyuria with saburra. Contrast-enhanced computed tomography revealed an abdominal abscess and air in the urinary bladder, therefore emergency laparotomy was performed. The operative findings included multiple diverticula along the mesenteric aspect of the small intestine, and two perforations with severe adhesion were identified. Each of the perforations was associated with an abdominal abscess and enterovesical fistula. We performed partial resection of the small intestine including the two perforations, and intra-abdominal lavage. Histopathological examination of the resected specimen revealed multiple diverticula in the small intestine. Enterovesical fistula associated with diverticulitis of the small intestine is extremely rare, our search of the literature revealing only five reported cases.

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A 63-year-old female was transferred to our critical care center due to a loss of consciousness. During the first examination, the patient's level of consciousness was JCS 200, blood pressure was unmeasurable, and ECG showed multifocal premature ventricular contractions. She was intubated and treated with the anti-arrhythmic drugs and cardioversion, however, these had no effect. Her ventricular arrhythmia was intractable and hemodynamics was unstable, therefore we applied a percutaneous cardio-pulmonary support (PCPS). After she was admitted to ICU, her family found the root of a plant in her bag, and we could then diagnose it as aconite poisoning. Ventricular arrhythmia returned to sinus rhythm 22 hours after admission, and the PCPS was wore off on the 3rd hospital day. Aconitine, mesaconitine and jesaconitine were detected in the serum. The level of these aconitum alkaloids decreased gradually to become undetectable two days later. We must keep aconite poisoning in mind as the cause of an intractable ventricular arrhythmia. It is important to apply PCPS without delay to maintain the hemodynamics in the case of aconite poisoning resistant to anti-arrhythmic drugs and cardioversion.

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