This study evaluated the outcome of out-of-hospital cardiac arrest and cardiopulmonary resuscitation (CPR) in Hakodate area, Japan, during the 18-month period. Data were prospectively collected according to a modified Utstein style. Between 1 January 2003 and 30 June 2004, out-of-hospital cardiac arrest was confirmed in 387 patients. CPR was attempted in 344 patients. Cardiac arrest of presumed cardiac etiology (181) was bystander-witnessed in 96 cases, 23 (24%) showed ventricular fibrillation or ventricular tachycardia (VF/VT) in the initial rhythm and 18 underwent defibrillation. In bystander-witnessed arrests, 21 (22%) bystanders performed CPR, 32 patients had spontaneous return of circulation, 24 survived until hospital admission, and 10 were alive 1 month later. Compared to other Utstein style studies, there were low rates of bystander CPR and defibrillation-effective VT/VF as initial rhythm in this area. Therefore the rate of survival to hospital discharge was very low. To improve the survival rate, we consider that continuing efforts should be made to promote the efficiency of bystander CPR and early defibrillation.

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We report a case of drug-induced pure red cell aplasia (PRCA) in a patient who became comatose after a subarachnoid hemorrhage. The patient had no subjective symptoms, and anemia was the only hematologically abnormal finding. Neurosurgical patients are frequently treated with the anti-epileptic agent diphenylhydantoin to prevent epilepsy, but several papers have reported diphenylhydantoin-induced PRCA. When treated with anti-epileptic agents, patients are at risk for skin reactions, neurogenic disorders, and other side effects when excessive doses are administered. Here, no causative medical agent was identified because the patient had been administered several medical agents, including diphenylhydantoin, which have anemia as a side effect. Dosages of these agents were, however, within the normal range and the blood concentration of diphenylhydantoin was below the standard limit at the time anemia developed. Since comatose patients cannot report subjective symptoms, diagnosis of anemia must be made based on objective manifestations and hematological findings. PRCA must be suspected if anemia symptoms appear rapidly in a patient receiving medical agents which have anemia as a side effect. With drug-induced PRCA there is a risk of PRCA even when the patient is administered standard drug dosages. If anemia is diagnosed, the causative drug must be discontinued immediately.

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Comminuted tibial fractures are often complicated by skin defects of the lower leg with exposed bone, and a variety of surgical flap methods have been used as treatment. We report a case of open tibial fracture where necrosis of the injured skin caused the tibial bone to become exposed and conservative treatment with basic fibroblast growth factor (bFGF) spray and prostaglandin E1 (PGE1) ointment accelerated granulation and coverage of this exposed bone. A 59-year-old male was admitted to our hospital after falling from a loading platform, and sustaining severe open left tibial pilon fractures. The patient was taken to the operating room for wound lavage and debridement. The wound was treated with primary closure, reduction of the fracture, and calcaneal traction. On the 7th day after injury, necrosis of the injured skin caused the tibial bone to become exposed. As the patient had a past history of arteriosclerotic obliteration (ASO), his wound was treated conservatively with bFGF spray and PGE1 ointment. After 78 days, this treatment led to good granulation coverage without infection. We describe this case and discuss its implications.

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