Objective: To determine characteristics and outcome among patients suffering in-hospital cardiac arrest, and assess factors influencing the survival.
Method: From January 2005 to June 2007, data of inpatients who received resuscitation for sudden cardiac arrest were collected by the Utstein style prospectively.
Result: 112 patients were included. 52.7% of cardiac arrest was occurred in coronary care unit and cardiology ward. 84 patients (75.0%) were witnessed immediately after cardiac arrest. Ventricular fibrillation or pulseless ventricular tachycardia was observed as initial cardiac rhythm in 24 patients (21.4%). Average time from collapse to resuscitation was 0.6 minutes, to defibrillation was 4.2 minutes, to intubation was 5.0 minutes, and to administration of epinephrine was 6.2 minutes. Overall, 55 of 112 patients (49.1%) were returned of spontaneous circulation and 13 patients (11.6%) were survived to discharge. 12 patients showed satisfactory neurological recovery (Cerebral performance category 1 or 2). Factors associated with return of circulation were VF/pulseless VT as the initial rhythm (odds ratio: 4.14, 95%CI: 1.45-32.65) and respiratory cause (odds ratio: 6.88, 95%CI: 1.45-32.65). Factors influenced survival to discharge were witness of arrest (odds ratio was not calculated), VF/pulseless VT as the initial rhythm (odds ratio: 12.6, 95%CI: 3.44-46.22), cardiogenic cause (odds ratio: 16.89, 95%CI: 2.12-135.72), and time from collapse to administration of epinephrine (odds ratio: 0.75).
Conclusion: A high survival rate and an excellent neurological function are expected by the cardiogenic arrest. But VF/pulseless VT as the initial rhythm was showed only 21.4% of in-hospital arrest rhythm. To improve the outcome of the in-hospital cardiac arrest, it seems that there was a limit only by the early defibrillation. About non-cardiogenic arrest, it is important to discover the warning sign of cardiac arrest.

View full abstract

Objectives: Acute myocardial infarction (AMI) is a typical emergency condition which has specific target therapy timeframes that are recommended by several guidelines and therefore is a suitable condition for evaluating quality of care. However, little is known about the present situation of these timeframes in Japan. The aim of our study was to evaluate emergency department performance for patients with AMI in Japan.
Methods: We evaluated the door-to-ECG time and door-to-catheter-lab time in 78 patients with AMI receiving percutaneous coronary intervention (PCI) in the Emergency Department (ED) of a single hospital in Japan during in the course of one year.
Results: The door-to-ECG mean time was 9.7 ± 4.8 minutes (median 8 min) with 77% of patients receiving an ECG within 10 min of arrival. The door-to-catheter-lab time was 55.7 ± 32.4 min (43 min). The door-to-ECG times during regular work hours and after-hours/weekend were 10.5 ± 1.7 min (8 min) and 9.4 ± 0.9 min (7.5 min) (p=0.462); for, door-to-catheter-lab time the times were 50.2 ± 9.9 min (35 min) and 54.1 ± 9.0 min (49 min) (p=0.506), respectively. Neither difference was founded to be statistically significant. The door-to-ECG times of patients with and without chest pain were 7.9 ± 0.6 min (7 min) and 15.1 ± 2.4 min (11.5 min), respectively and the difference was statistically significant (p<0.001), whereas door-to-catheter-lab times were 47.3 ± 4.7 min (32 min) and 80.3 ± 23.0 min (56.5 min), respectively, the difference was not statistically significant (p=0.056). The door-to-ECG times of patients presenting by private conveyance and ambulance were 15.7 ± 9.5 min (11.5 min) and 7.5 ± 4.8 min (7 min), respectively, and the difference was statistically significant (p<0.001), whereas in door-to-catheter-lab time was 67.9 ± 27.2 min (60 min) and 51.2 ± 69.4 min (31 min), respectively and the difference was not statistically significant (p=0.324).
Conclusion: We observed no differences in door-to-ECG time and door-to-catheter-lab time in terms of the time of day or week of presenting. Our study also brought into light the fact that atypical presentation and presenting by private conveyance significantly increased the time to appropriate management. These results warrant further investigation into how these patients are managed, and how to develop the diagnostic skills of emergency physicians.

View full abstract

We report a case of a patient with abdominal pain due to a ruptured right gastroepiploic arterial aneurysm. A 69-year-old man who had a previous diagnosis of hypertension presented with gradually increasing pain in his upper abdomen. His vital signs were stable and physical examination revealed slight abdominal distension and mild tenderness in the upper to mid abdomen. Blood tests revealed a haemoglobin level of 6.2g/dL. Enhanced Multi-Detector CT (MDCT) demonstrated an aneurysm 2cm in diameter with massive intraperitoneal hemorrhage. Maximum Intensity Projection (MIP) revealed a saccular aneurysm with a narrow neck arising from the right gastroepiploic artery. Transcatheter arterial embolization (TAE) was selected as the treatment of choice for the ruptured aneurysm because the patient refused to undergo an operation. We successfuly performed TAE using an interlocking detachable coil (IDC) into the aneurysm while preserving blood flow of the parent artery. Although rupture of gastroepiploic arterial aneurysm is rare condition. TAE using IDC is a treatment of choice for this unusual problem.

View full abstract

A 50-year-old man was admitted to our hospital with complaints of blindness and consciousness disturbance. Neurosurgeons suspected “top of the basilar” syndrome because of atrial fibrillation and bilateral basal ganglia lesions detected by head magnetic resonance imaging (MRI); however, angiography of the vertebral arteries confirmed the absence of the syndrome. He became comatose and had severe metabolic acidosis; therefore methanol intoxication was strongly suspected. He was admitted to the intensive care unit and intubated; he received hemodialysis and was administered ethanol and activated folate. He recovered consciousness but remained blind and disoriented. His head MRI revealed bilateral putaminal and subcortical hemorrhagic necrosis. He was transferred to a mental hospital because he was in a delusional state. Delay in treatment can lead to serious sequelae in methanol intoxication, and it takes several days to measure the methanol level in the blood. It is necessary to diagnose methanol intoxication on the basis of clinical findings, serum osmolal gap, and the pathognomonic changes detected by head computed tomography (CT) or MRI.

View full abstract

A 42-year-old female with a toothache, fever, submandibular and neck swelling was initially misdiagnosed to have flu by local medical institutions, however, her symptoms deteriorated and she was thereafter transferred to our hospital. On arrival, she demonstrated septic shock. As her neck and chest CT indicated pyothorax with submandibular and mediastinal abscesses, she thereafter underwent a neck incision, a tracheotomy and bilateral tube thoracostomies. An investigation of her oral cavity disclosed a dilation of the opening of the submandibular duct. Accordingly, she was diagnosed to have Ludwig's angina due to the development of a salivary duct stone, thus resulting in descending mediastinitis, pyothorax and septic shock. Multidisciplinal approaches, such as mechanical ventilation, antipyretic drugs and multiple CT guide drainage for multicapsulated pyothorax resulted in an improvement of her symptoms. She was discharged on foot on the 58th hospital day. Ludwig's angina is a submandibular abscess mainly induced by dental caries. When the infection spreads through oto-pharyngeal loose connective tissue, it can cause meningitis, descending mediastinitis and pyothorax. Ludwig's angina is rare, however, it can be lethal. Therefore, physicians should include the possibility of Ludwig's angina in the differential diagnosis when encountering a patient demonstrating submandibular swelling with inflammation signs.

View full abstract

When electrical current passes through a living organism electrical injury can occur. While lightning injuries are similar to electric injuries some characteristics differ. This includes the circumstances surrounding the injury, associated clinical symptoms, and the prognosis related to each type of injury. A 66-year-old man and a 52-year-old woman were both struck by lightning while sheltering beneath a large tree. Upon admission to our hospital, physical examination revealed feathering burns on both patients. The man was unable to be resuscitated and died from cardio pulmonary arrest but the woman was discharged on the 7th day of admission with no significant complications. Feathering burns can appear when an electrical spark discharge comes in contact with the surface of the human body. From an electrical engineering perspective, an electrical spark discharge spreads out like branches allowing the direction of the current to be known. From examination of both patients' feathering burns and information obtained from the survivor, the outcome of patients struck by lightning was speculated through the direction of an electric current. In the case of the man with CPA, a phenomenon called “side flash” had a large impact on the prognosis. It is known that the prevention of being struck by lightning is very important; however, lightning injury from “side flash” is not well understood. Future research can contribute to measures which may decrease the number of people who suffers from lightning injury.

View full abstract