The following evidences regarding therapeutics for severe sepsis and septic shock were published in 2007: 1)Intravenous immunoglobulin--the effectiveness on survival in adult severe sepsis was reported in a systematic review. However, the opposite result was reported in a randomized controlled trial. 2) Activated protein C--although the bleeding tendency was a significant problem, the efficacy on survival in severe sepsis was recognized again in a large scale database. However, the opposite result was reported in the other systematic review. 3) Antithrombin--effectiveness had not been recognized in a systematic review. The question whether antithrombin is effective for septic DIC is still unanswered. 4) Polymyxin B-immobilized fiber column--the potential effectiveness was reported by a systematic review. However, quality controlled prospective study will be needed. 5) Steroids--effectiveness for septic shock could not be proven in a RCT, while potential effectiveness for ARDS was shown in another RCT. Further study should be done in a large scale.

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Spontaneous bladder rupture, especially associated with neurogenic bladder dysfunction, is a rare disease. Intraperitoneal bladder rupture often causes peritoneal irritation and paralytic ileus, which suggests gastrointestinal perforation or strangulation ileus. Therefore, it is difficult to make a definite diagnosis until laparotomy. We report a case of spontaneous bladder rupture associated with neurogenic bladder dysfunction. The patient was an 88-years-old man who was admitted to our hospital with a complaint of lower abdominal pain with peritoneal irritation. We made a diagnosis of spontaneous bladder rupture, based on CT findings, immediately after cystography. We review and discuss 27 cases of spontaneous bladder rupture in neurogenic bladder that have been reported in Japan. Intraperitoneal bladder rupture must be taken into consideration in the differential diagnosis of unidentified fluid in the abdominal cavity.

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A 31-year-old man was admitted to our hospital in a state of intoxication with a Phenobarbital-Chlorpromazine-Promethazine combination (Vegetamin B^®). On arrival at the hospital, the man was in a deep coma. After transfer to intensive care unit, his spontaneous breathing had stopped and his brainstem reflex was absent. Toxicology studies showed serum concentrations of Phenobarbital at 122.8μg/ml. Chest and abdominal X rays showed gastric mass formation. We began gastric lavage, administration of multiple-dose activated charcoal, and charcoal hemoperfusion. After 3 rounds of hemoperfusion, the man temporarily regained consciousness and the serum concentrations decreased to 22.5μg/ml. But 12 hours later, he relapsed into coma and the serum concentrations increased again, to 101.2μg/ml. We judged this to be caused by a “charcoal-drug mass” in the ascending-transverse colon, which showed on an abdominal X ray. We restarted charcoal hemoperfusion, together with whole bowel irrigation. The serum concentrations of Phenobarbital decreased gradually, and the man made a gradual recovery and was discharged from the hospital 3 weeks after admission. We recommend that administration of multiple-dose activated charcoal for a life-threatening amount of Vegetamin^® overdose patients be accompanied by co-administration of a cathartic and that administration should be discontinued and treated with whole bowel irrigation if the charcoal does not appear in the stools within 12 hours, not only to decrease the risk of bowel obstruction but also to hasten the elimination of “charcoal-drug complex”.

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A 63-year-old man injured his left forefinger during farm work, resulting in tetanus. His blood pressure (BP) became unstable as a result of autonomic dysfunction due to the tetanus. Since administration of magnesium sulfate had insufficient effects on stabilization of his BP, α-methyldopa was added. Excellent stabilization of BP without adverse effects was achieved with the addition of α-methyldopa. Beta-blockers have been reported to be dangerous in the treatment of unstable BP due to tetanus. Therefore, special attention has focused on inhibition of catecholamine release in the treatment of autonomic dysfunction due to tetanus. Although magnesium sulfate has been reported to be effective for the treatment of tetanus by inhibiting catecholamine release, it has not been commonly used in Japan. Alpha-methyldopa, as well as clonidine, is an inhibitor of the central α₂ receptor and inhibits the release of catecholamine. Clonidine has been reported to be effective for the treatment of tetanus, but its use has decreased because of adverse effects. This case suggests that a combination of magnesium sulfate and α-methyldopa is useful in controlling the autonomic dysfunction in tetanus. It also seems to be worthwhile to examine whether other central α₂-adrenergic receptor agonists may be effective in the management of tetanus.

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Traumatic diaphragmatic rupture (TDR) cannot be excluded in patients receiving mechanical ventilation (MV). However, few reports have documented actual cases. We present the case of a 64-year-old man who was injured in a motorcycle accident who developed TDR, but the diagnosis was delayed because he needed MV due to an associated head injury. On admission, he was somnolent but did not need intubation. Radiological examinations showed left rib fractures and a subdural hematoma. A small mass was identified on the left diaphragm, though it could not be positively identified as TDR. One hour later, the patient's mental status deteriorated, and a craniotomy was performed. Postoperatively, the patient received MV. On hospital day 7, chest CT showed no abnormality. On day 20, MV was stopped. Serial chest radiographs done on the following 3 days showed no changes, but the day 23 radiograph revealed a stomach gas bubble in the left thoracic cavity. TDR was diagnosed and repaired surgically. After surgery, the admission coronal and 3-dimensional CT images were reformatted; the admission coronal CT clearly demonstrated the TDR. Furthermore, based on the day 7 CT scans in which no organ was incarcerated, a 3-dimensional CT of the ruptured diaphragm could be reconstructed. Coronal and 3-dimensional CT provide significant information of diaphragmatic rupture.

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We present a case of nontraumatic acute subdural hematoma (SDH) caused by rupture of a middle cerebral artery (MCA) aneurysm. A 74-year-old man presented after sudden onset of moderate headache. Neurological examination on arrival revealed no abnormalities, but initial CT showed a thin acute SDH on the right. Since the patient had no history of head trauma, his illness was diagnosed as nontraumatic acute SDH. Immediately thereafter, his condition deteriorated acutely and he became unresponsive. Repeat CT showed a marked increase of SDH with impending transtentorial herniation. Emergency right frontotemporal craniotomy was performed to remove the hematoma. Postoperatively, 3 dimensional CT angiography revealed a large aneurysm (22 mm in diameter) at the right MCA bifurcation. Aneurysm clipping was carried out on the same day. The postoperative course was satisfactory and he was discharged 3 weeks after surgery without any neurological deficits. Despite its rarity, rupture of an intracranial aneurysm should be kept in mind as a possible cause of nontraumatic acute SDH, because early diagnosis and definitive treatment can improve the prognosis. The possible mechanism of this condition is also discussed.

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This case involves a 29-year-old male who had, until 8 years ago, undergone radiation therapy for pituitary germinoma and was taking 20mg hydrocortisone daily for panhypopituitarism. Suffering profuse diarrhea, he was transported to our emergency department with exhaustion and hypothermia. Hypothermia treatment started with electric blankets for surface rewarming and warm gastric lavage for internal rewarming. Hypotension resulted from rewarming and rewarming shock suspected. Fluid loading was performed with no response. Dopamine was started but hypotension continued. Acute adrenal insufficiency was suspected due to the patient's medical history and catecholamine resistant shock, so 100 mg of hydrocortisone was administered intravenously 11 hours after arrival. Blood pressure slowly increased, allowing gradual reduction of fluid loading and dopamine. Before administering the hydrocortisone, serum cortisol concentration was 1.4μg/dl. On the 4th day of hospitalization, the patient was transferred from ICU and on the 11th day received an ambulatory discharge. Acute adrenal insufficiency is well known, but emergency room encounters are rare. Symptoms vary and lab findings are non-specific, making diagnosis difficult. When faced with catecholamine resistant shock, early diagnosis and treatment can influence the prognosis. Based upon the patient's medical history and developments, acute adrenal insufficiency should initially be suspected and steroids administered.

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